MEDICARE: CANDOR COUNSELING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH 11836	FL
2	106H00000X	Marriage & Family Therapist	MT2804	FL

General Provider Information

NPI Number	:	1033556063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANDOR COUNSELING LLC

Provider Business Mailing Address
First Line	:	2830 NW 41ST ST
Second Line	:	SUITE J
City	:	GAINESVILLE
State	:	FL
Zip	:	32606-6667
Country	:	US
Telephone Number	:	352-284-3747
Fax Number	:

Provider Business Practice Location Address
First Line	:	2830 NW 41ST ST
Second Line	:	SUITE J
City	:	GAINESVILLE
State	:	FL
Zip	:	32606-6667
Country	:	US
Telephone Number	:	352-284-3747
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	EDIE J. SIEMANN
Credential	:	LMHC
Telephone Number	:	352-284-3747

Provider Enumeration Date	:	05/31/2013
Last Update Date	:	02/03/2014

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Directions to “CANDOR COUNSELING LLC ” Practice Location

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