Provider Demographics
NPI:1477848174
Name:ELLRICH, CANDACE DOMAYER (LCPC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:DOMAYER
Last Name:ELLRICH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10455 FALLS RD
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-3614
Mailing Address - Country:US
Mailing Address - Phone:410-292-1115
Mailing Address - Fax:
Practice Address - Street 1:10455 FALLS RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-3614
Practice Address - Country:US
Practice Address - Phone:410-292-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4025101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional