Provider Demographics
NPI:1497444251
Name:MOORE, CANDICE (LPC, MA)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 E HWY 6
Mailing Address - Street 2:UNIT B
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383
Mailing Address - Country:US
Mailing Address - Phone:773-269-7560
Mailing Address - Fax:
Practice Address - Street 1:123 E HWY 6
Practice Address - Street 2:UNIT B
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383
Practice Address - Country:US
Practice Address - Phone:773-269-7560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018752101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty