Provider Demographics
NPI:1780339382
Name:STONE, CANDICE BROOKE
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:BROOKE
Last Name:STONE
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 1:15311 LESLIE ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1992
Mailing Address - Country:US
Mailing Address - Phone:540-735-6154
Mailing Address - Fax:
Practice Address - Street 1:15311 LESLIE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1992
Practice Address - Country:US
Practice Address - Phone:540-735-6154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451019052101YM0800X
MI6401223213101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health