Provider Demographics
NPI:1487136636
Name:VAN DER STELT, CANDACE MARIE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:MARIE
Last Name:VAN DER STELT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:MARIE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7517 BLAIR RD APT 11
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-4024
Mailing Address - Country:US
Mailing Address - Phone:308-380-7492
Mailing Address - Fax:
Practice Address - Street 1:3800 RESERVOIR RD NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2113
Practice Address - Country:US
Practice Address - Phone:202-784-2858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCSLP001019235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist