Provider Demographics
NPI:1942317334
Name:FAIR, CANDACE D (LCSW)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:D
Last Name:FAIR
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 W ST FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775
Mailing Address - Country:US
Mailing Address - Phone:573-547-1145
Mailing Address - Fax:
Practice Address - Street 1:12 N KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775
Practice Address - Country:US
Practice Address - Phone:573-547-3116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005110101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO114540OtherBLUE CROSS