Provider Demographics
NPI:1225312929
Name:ELLIOTT, CANDICE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:ELLIOTT
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:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-0031
Mailing Address - Country:US
Mailing Address - Phone:541-967-3866
Mailing Address - Fax:
Practice Address - Street 1:1255 HILYARD ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3718
Practice Address - Country:US
Practice Address - Phone:541-686-7376
Practice Address - Fax:541-434-7498
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4121101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional