Provider Demographics
NPI:1689991085
Name:HART, CANDICE LEIGH (LPC-CANDIDATE)
Entity Type:Individual
Prefix:MS
First Name:CANDICE
Middle Name:LEIGH
Last Name:HART
Suffix:
Gender:F
Credentials:LPC-CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W 6TH AVE
Mailing Address - Street 2:STE. 117
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010
Mailing Address - Country:US
Mailing Address - Phone:918-771-8653
Mailing Address - Fax:
Practice Address - Street 1:119 W 6TH AVE
Practice Address - Street 2:STE. 117
Practice Address - City:BRISTOW
Practice Address - State:OK
Practice Address - Zip Code:74010
Practice Address - Country:US
Practice Address - Phone:918-771-8653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK310698171M00000X, 251B00000X
OK108211175T00000X
225400000X
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200555170BMedicaid
OK200555170AMedicaid
OK310698Medicaid