Basic Information
Provider Information | |||||||||
NPI: | 1154543783 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | CANDACE | ||||||||
MiddleName: | PETERSON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2000 FRONTIS PLAZA BLVD | ||||||||
Address2: | SUITE 200 (FORSYTH MEDICAL GROUP) | ||||||||
City: | WINSTON-SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271035616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3362772435 | ||||||||
FaxNumber: | 3362779275 | ||||||||
Practice Location | |||||||||
Address1: | 3821 FORRESTGATE DRIVE | ||||||||
Address2: | DBA FORSYTH BEHAVIOR HEALTH | ||||||||
City: | WINSTON-SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 27103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3362771811 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2007 | ||||||||
LastUpdateDate: | 03/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 3871 | NC | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YA0400X | 706 | NC | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.