Provider Demographics
NPI:1467869156
Name:BENNER, CANDACE D (MA, LPC, CCTP, EMDR)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:D
Last Name:BENNER
Suffix:
Gender:F
Credentials:MA, LPC, CCTP, EMDR
Other - Prefix:
Other - First Name:CANDEE
Other - Middle Name:
Other - Last Name:SIMCOX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CATP, CFTP
Mailing Address - Street 1:PO BOX 114
Mailing Address - Street 2:
Mailing Address - City:ROBY
Mailing Address - State:MO
Mailing Address - Zip Code:65557-0114
Mailing Address - Country:US
Mailing Address - Phone:573-315-3848
Mailing Address - Fax:573-312-3848
Practice Address - Street 1:19871 SACKETT LN
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65583-3510
Practice Address - Country:US
Practice Address - Phone:573-315-3848
Practice Address - Fax:573-312-3848
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-15
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014034465101YM0800X, 101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490021314Medicaid