Provider Demographics
NPI:1639474695
Name:ANTHONY, CANDACE ELIS (MED, LPC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:ELIS
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631A ARMAND PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2225
Mailing Address - Country:US
Mailing Address - Phone:314-459-7313
Mailing Address - Fax:
Practice Address - Street 1:2631A ARMAND PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-2225
Practice Address - Country:US
Practice Address - Phone:314-459-7313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 101Y00000X
MO2011013937101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor