Provider Demographics
NPI:1073896742
Name:SMALL, CANDACE DARLENE (LPA)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:DARLENE
Last Name:SMALL
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 FAULKENBERRY RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-4447
Mailing Address - Country:US
Mailing Address - Phone:704-433-2740
Mailing Address - Fax:
Practice Address - Street 1:1415 FAULKENBERRY RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-4447
Practice Address - Country:US
Practice Address - Phone:704-433-2740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4167103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist