Provider Demographics
NPI:1356862874
Name:NELSON, CANDACE MICHELLE (BCABA)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:MICHELLE
Last Name:NELSON
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 LONGMIRE DR # 256B
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-5489
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 E 29TH ST STE 190
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-4211
Practice Address - Country:US
Practice Address - Phone:979-985-9503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0-16-7314103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX47-3705562OtherGROUP TAX ID