Provider Demographics
NPI:1881152403
Name:COULTER, CANDICE VIDA (LPC, NCC)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:VIDA
Last Name:COULTER
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-1650
Mailing Address - Fax:704-316-1651
Practice Address - Street 1:9929 REA RD
Practice Address - Street 2:STE 201
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173
Practice Address - Country:US
Practice Address - Phone:704-316-1650
Practice Address - Fax:704-316-1651
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11636101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional