Basic Information
| Provider Information | |||||||||
| NPI: | 1003155078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLASE | ||||||||
| FirstName: | CANDACE | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCPAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14601 ROXBURY RD | ||||||||
| Address2: | |||||||||
| City: | GLENELG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217379611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432800677 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5560 STERRETT PL | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210442601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4435464000 | ||||||||
| FaxNumber: | 4435464005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2013 | ||||||||
| LastUpdateDate: | 02/11/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | ATC003 | MD | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.