Basic Information
| Provider Information | |||||||||
| NPI: | 1689711418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARRELL | ||||||||
| FirstName: | CANDACE | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 BALTIMORE PIKE STE 208 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190642852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155907555 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 BALTIMORE PIKE STE 208 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190642852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155907555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 08/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0904006461 | VA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | CW020724 | PA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 103777332 | 05 | PA | MEDICAID |