Provider Demographics
NPI:1891192878
Name:WILSON, CANDACE DOROTHY (LPC)
Entity Type:Individual
Prefix:MS
First Name:CANDACE
Middle Name:DOROTHY
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:PROF
Other - First Name:CANDACE
Other - Middle Name:DOROTHY
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:26 DRAPER TER
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-4440
Mailing Address - Country:US
Mailing Address - Phone:973-583-9604
Mailing Address - Fax:
Practice Address - Street 1:1314 PARK AVE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-3253
Practice Address - Country:US
Practice Address - Phone:973-755-3392
Practice Address - Fax:973-755-4758
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00507700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional