Provider Demographics
NPI:1366747727
Name:BRONAUGH, CANDICE LYNN (LMT, PTA)
Entity type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:LYNN
Last Name:BRONAUGH
Suffix:
Gender:F
Credentials:LMT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31235 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77354-6238
Mailing Address - Country:US
Mailing Address - Phone:979-900-0830
Mailing Address - Fax:
Practice Address - Street 1:31235 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-6238
Practice Address - Country:US
Practice Address - Phone:979-900-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-17
Last Update Date:2024-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT111469225700000X
TX2182567225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist