Provider Demographics
NPI:1437775095
Name:CLARK, CANDACE DANIELLE (LPC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:DANIELLE
Last Name:CLARK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26099 HIGHWAY 59
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOXLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36551
Mailing Address - Country:US
Mailing Address - Phone:251-308-6160
Mailing Address - Fax:251-262-6472
Practice Address - Street 1:26099 HIGHWAY 59
Practice Address - Street 2:SUITE A
Practice Address - City:LOXLEY
Practice Address - State:AL
Practice Address - Zip Code:36551
Practice Address - Country:US
Practice Address - Phone:251-308-6160
Practice Address - Fax:251-262-6472
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4279101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional