1538405816 NPI number — CANDACE IRENE GUILLORY MS, LMHC, ATR

Table of content: CANDACE IRENE GUILLORY MS, LMHC, ATR (NPI 1538405816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538405816 NPI number — CANDACE IRENE GUILLORY MS, LMHC, ATR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUILLORY
Provider First Name:
CANDACE
Provider Middle Name:
IRENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LMHC, ATR
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:
1538405816
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3747 RIVERWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46214-4030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-320-4110
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
719 INDIANA AVE STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46202-6149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-274-2548
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2012

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: 101YM0800X , with the licence number:  39003470A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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