Healthcare Provider Details

I. General information

NPI: 1851605083
Provider Name (Legal Business Name): CANDICE NICOLE CLAIBORNE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 BROAD ST STE 350
ROME GA
30161-3092
US

IV. Provider business mailing address

221 TECHNOLOGY PKWY NW
ROME GA
30165-1369
US

V. Phone/Fax

Practice location:
  • Phone: 706-295-2028
  • Fax: 706-295-2062
Mailing address:
  • Phone: 706-295-5331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY003955
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: