Provider Demographics
NPI:1306182423
Name:DAVIS, CANDACE MARIE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:MARIE
Last Name:DAVIS
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 1:10525 N MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-5117
Mailing Address - Country:US
Mailing Address - Phone:405-301-3279
Mailing Address - Fax:
Practice Address - Street 1:10525 N MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-5117
Practice Address - Country:US
Practice Address - Phone:405-301-3279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-17
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional