Healthcare Provider Details

I. General information

NPI: 1114559754
Provider Name (Legal Business Name): CANDES NICOLE ANDERSON-GRAY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CANDES NICOLE GRAY

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29550 FIVE MILE RD
LIVONIA MI
48154-3710
US

IV. Provider business mailing address

6549 TOWN CENTER DR STE A
CLARKSTON MI
48346-4824
US

V. Phone/Fax

Practice location:
  • Phone: 800-395-3223
  • Fax:
Mailing address:
  • Phone: 800-395-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801115503
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: