Provider Demographics
NPI:1821487513
Name:COSTON, CANDACE (LCSWA)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:COSTON
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6220 THERMAL RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-5630
Mailing Address - Country:US
Mailing Address - Phone:910-520-8723
Mailing Address - Fax:
Practice Address - Street 1:1811 BADIN RD
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-9742
Practice Address - Country:US
Practice Address - Phone:910-520-8723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-18
Last Update Date:2015-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0084361041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC56-0554413OtherALEXANDER YOUTH NETWORK