1174059091 NPI number — MRS. CANDACE SPROUSE LISW-CP, OSW-C

Table of content: MRS. CANDACE SPROUSE LISW-CP, OSW-C (NPI 1174059091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174059091 NPI number — MRS. CANDACE SPROUSE LISW-CP, OSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPROUSE
Provider First Name:
CANDACE
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LISW-CP, OSW-C
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:
1174059091
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1708 SWEET APPLE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOUNTAIN INN
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29644-3433
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-905-8802
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 DUTCH FORK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAPIN
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29036-7576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-338-2885
Provider Business Practice Location Address Fax Number:
864-626-0412
Provider Enumeration Date:
05/11/2017

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: 1041C0700X , with the licence number:  8675 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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