Provider Demographics
NPI:1497489769
Name:HUBBARD, CANDACE MONIQUE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:MONIQUE
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 BLUE STREAM DR
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-3962
Mailing Address - Country:US
Mailing Address - Phone:817-683-5205
Mailing Address - Fax:
Practice Address - Street 1:1229 E PLEASANT RUN RD STE 305
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4229
Practice Address - Country:US
Practice Address - Phone:469-518-6034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89128101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor