Basic Information
| Provider Information | |||||||||
| NPI: | 1902308935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANDIDO-HERNANDEZ | ||||||||
| FirstName: | MARIELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 616 MAYFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953570147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096143042 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1539 MCHENRY AVE | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097020139 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2018 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.