Provider Demographics
NPI:1770878514
Name:KING, CANDICE
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:KING
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 1:1202 CORBIN RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-2323
Mailing Address - Country:US
Mailing Address - Phone:419-476-7441
Mailing Address - Fax:
Practice Address - Street 1:14930 LAPLAISANCE RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-3880
Practice Address - Country:US
Practice Address - Phone:734-240-3850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0700328101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional