Provider Demographics
NPI:1811607732
Name:PARK, CANDACE (PHD)
Entity type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SWEET MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8045
Mailing Address - Country:US
Mailing Address - Phone:931-629-6013
Mailing Address - Fax:
Practice Address - Street 1:205 SWEET MAPLE DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-8045
Practice Address - Country:US
Practice Address - Phone:931-629-6013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4323101YP2500X
AL3471101YP2500X
KY262239101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional