Provider Demographics
NPI:1679839542
Name:MORTENSEN, CANDICE MARIE (LCMHCA)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:MARIE
Last Name:MORTENSEN
Suffix:
Gender:F
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8512 SIX FORKS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3256
Mailing Address - Country:US
Mailing Address - Phone:919-277-0253
Mailing Address - Fax:
Practice Address - Street 1:8512 SIX FORKS RD STE 101
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3256
Practice Address - Country:US
Practice Address - Phone:919-277-0253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8148206-6009101YM0800X
NCA18236101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health