Provider Demographics
NPI:1114361292
Name:HALL, CANDICE NICOLE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:NICOLE
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:N
Other - Last Name:SHIPP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10175 FORTUNE PKWY
Mailing Address - Street 2:UNIT 903
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-6746
Mailing Address - Country:US
Mailing Address - Phone:904-538-0713
Mailing Address - Fax:904-538-0714
Practice Address - Street 1:3706 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE A
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-0958
Practice Address - Country:US
Practice Address - Phone:706-863-9699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-13-12835103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst