Provider Demographics
NPI:1497189906
Name:HALL, CANDICE
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 BOWSER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806-4429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4110 BOWSER AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-4429
Practice Address - Country:US
Practice Address - Phone:260-602-1964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2025-10-09
Deactivation Date:2014-04-02
Deactivation Code:
Reactivation Date:2016-04-27
Provider Licenses
StateLicense IDTaxonomies
IN39002839A101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health