MEDICARE: MISS CANDRA JAMAE POITRAS MAC

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	101Y00000X	Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1861949893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CANDRA JAMAE POITRAS MAC

Provider Business Mailing Address
First Line	:	921 TIMBERWOOD CROSSING CT
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63031-7518
Country	:	US
Telephone Number	:	314-803-0280
Fax Number	:

Provider Business Practice Location Address
First Line	:	567 MADISON ST
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-2747
Country	:	US
Telephone Number	:	636-699-0872
Fax Number	:

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

Provider Enumeration Date	:	09/07/2016
Last Update Date	:	09/07/2016

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