Provider Demographics
NPI:1114212974
Name:PRONOVOST, CANDACE NICHOLE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:NICHOLE
Last Name:PRONOVOST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 MAPLE ST
Mailing Address - Street 2:325
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-2202
Mailing Address - Country:US
Mailing Address - Phone:413-737-9544
Mailing Address - Fax:413-737-4455
Practice Address - Street 1:130 MAPLE ST
Practice Address - Street 2:325
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2202
Practice Address - Country:US
Practice Address - Phone:413-737-9544
Practice Address - Fax:413-737-4455
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor