Provider Demographics
NPI:1639408016
Name:ELL, CANDACE J
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:J
Last Name:ELL
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 1:101 EAST BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501
Mailing Address - Country:US
Mailing Address - Phone:701-222-0386
Mailing Address - Fax:701-255-4891
Practice Address - Street 1:515 1/2 E BROADWAY AVE STE 106
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4408
Practice Address - Country:US
Practice Address - Phone:701-751-0443
Practice Address - Fax:701-751-1616
Is Sole Proprietor?:No
Enumeration Date:2009-12-15
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1615101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND3000Medicaid