Healthcare Provider Details

I. General information

NPI: 1790978245
Provider Name (Legal Business Name): CANDICE JOI HUNTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2007
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 JOLIET ST
DYER IN
46311-1705
US

IV. Provider business mailing address

PO BOX 1000
DYER IN
46311-0800
US

V. Phone/Fax

Practice location:
  • Phone: 219-322-5747
  • Fax: 219-864-2282
Mailing address:
  • Phone: 219-864-2107
  • Fax: 219-864-2251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number165709
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01065064A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: