Healthcare Provider Details

I. General information

NPI: 1639474695
Provider Name (Legal Business Name): CANDACE ELIS ANTHONY M.ED., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 12/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2631A ARMAND PL
SAINT LOUIS MO
63104-2225
US

IV. Provider business mailing address

2631A ARMAND PL
SAINT LOUIS MO
63104-2225
US

V. Phone/Fax

Practice location:
  • Phone: 314-459-7313
  • Fax:
Mailing address:
  • Phone: 314-459-7313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2011013937
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: