Provider Demographics
NPI:1902408123
Name:CONANT, CANDACE MARIE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:MARIE
Last Name:CONANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1642
Mailing Address - Country:US
Mailing Address - Phone:715-896-8771
Mailing Address - Fax:
Practice Address - Street 1:1021 N SUPERIOR AVE STE 13
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-1192
Practice Address - Country:US
Practice Address - Phone:608-387-9638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19293-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)