Provider Demographics
NPI:1598191322
Name:MINOR, CANDY D
Entity Type:Individual
Prefix:
First Name:CANDY
Middle Name:D
Last Name:MINOR
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 1:3450 HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-7201
Mailing Address - Country:US
Mailing Address - Phone:601-321-2497
Mailing Address - Fax:601-321-2497
Practice Address - Street 1:3450 HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-7201
Practice Address - Country:US
Practice Address - Phone:601-321-2497
Practice Address - Fax:601-321-2497
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3085101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018209Medicaid