Provider Demographics
NPI:1114050176
Name:HUMPHRIES, CANDACE CROSBY (MS)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:CROSBY
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 SMITH AVE
Mailing Address - Street 2:SUITE M
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5739
Mailing Address - Country:US
Mailing Address - Phone:229-225-5208
Mailing Address - Fax:229-227-5458
Practice Address - Street 1:1102 SMITH AVE
Practice Address - Street 2:SUITE M
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5739
Practice Address - Country:US
Practice Address - Phone:229-225-5208
Practice Address - Fax:229-227-5458
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003809101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional