1013352012 NPI number — CANDICE CLAIRE EBBESEN MA, EDS MFT

Table of content: CANDICE CLAIRE EBBESEN MA, EDS MFT (NPI 1013352012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013352012 NPI number — CANDICE CLAIRE EBBESEN MA, EDS MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EBBESEN
Provider First Name:
CANDICE
Provider Middle Name:
CLAIRE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, EDS MFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013352012
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
395 S CENTER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07050-3205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-780-0905
Provider Business Mailing Address Fax Number:
973-673-5782

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 WAYNE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07302-5573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-780-0905
Provider Business Practice Location Address Fax Number:
973-673-5782
Provider Enumeration Date:
05/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  37F100175300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 216352 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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