=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588823967
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDIS SHERELL DANZY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2008
-----------------------------------------------------
Last Update Date | 02/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2693 FOREST HILLS RD SW
-----------------------------------------------------
City | WILSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27893-8611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-234-7800
-----------------------------------------------------
Fax | 704-982-5279
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 180
-----------------------------------------------------
City | BLACK CREEK
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27813-0180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P018015
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------