Basic Information
| Provider Information | |||||||||
| NPI: | 1255637138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEWELL | ||||||||
| FirstName: | CANDICE | ||||||||
| MiddleName: | PETTY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPCA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETTY | ||||||||
| OtherFirstName: | CANDICE | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 350 PEE DEE AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280014945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049861500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 S POST RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281526270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044764027 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A8308 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.