Provider Demographics
NPI:1013352012
Name:EBBESEN, CANDICE CLAIRE (MA, EDS MFT)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:CLAIRE
Last Name:EBBESEN
Suffix:
Gender:F
Credentials:MA, EDS MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-3205
Mailing Address - Country:US
Mailing Address - Phone:201-780-0905
Mailing Address - Fax:973-673-5782
Practice Address - Street 1:104 WAYNE ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-5573
Practice Address - Country:US
Practice Address - Phone:201-780-0905
Practice Address - Fax:973-673-5782
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37F100175300106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ216352Medicaid