Provider Demographics
NPI:1508146002
Name:MCKENZIE, CANDACE DALE (MACP, MFTI)
Entity Type:Individual
Prefix:MISS
First Name:CANDACE
Middle Name:DALE
Last Name:MCKENZIE
Suffix:
Gender:F
Credentials:MACP, MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 GENOA CT
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-5249
Mailing Address - Country:US
Mailing Address - Phone:310-795-6537
Mailing Address - Fax:
Practice Address - Street 1:327 DAHLONEGA ST STE B902
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2493
Practice Address - Country:US
Practice Address - Phone:310-795-6537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-28
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001408106H00000X
CALMFT83315106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist