Provider Demographics
NPI:1942505623
Name:THORNBURG, CANDACE NICOLE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:NICOLE
Last Name:THORNBURG
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 1:1106 MINEOLA CIR
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-5516
Mailing Address - Country:US
Mailing Address - Phone:727-422-7791
Mailing Address - Fax:
Practice Address - Street 1:1106 MINEOLA CIR
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-5516
Practice Address - Country:US
Practice Address - Phone:727-422-7791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst