MEDICARE: CANDACE ELIS ANTHONY M.ED., LPC

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	104100000X	Social Worker
2	101Y00000X	Counselor
3	101YP2500X	Professional Counselor	2011013937	MO

General Provider Information

NPI Number	:	1639474695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDACE ELIS ANTHONY M.ED., LPC

Provider Business Mailing Address
First Line	:	2631A ARMAND PL
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-2225
Country	:	US
Telephone Number	:	314-459-7313
Fax Number	:

Provider Business Practice Location Address
First Line	:	2631A ARMAND PL
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-2225
Country	:	US
Telephone Number	:	314-459-7313
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2011
Last Update Date	:	12/30/2018

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