Provider Demographics
NPI:1609519958
Name:LONG, CANDICE E
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:E
Last Name:LONG
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 1:1101 BEAUMONT CENTRE LN APT 7207
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1763
Mailing Address - Country:US
Mailing Address - Phone:219-688-4064
Mailing Address - Fax:
Practice Address - Street 1:2250 THUNDERSTICK DR STE 1104
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-9009
Practice Address - Country:US
Practice Address - Phone:859-254-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator