Provider Demographics
NPI:1033001631
Name:CLARK, CANDICE (MED, LMHC)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:CLARK
Suffix:
Gender:F
Credentials:MED, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12708 SW 21ST ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-2602
Mailing Address - Country:US
Mailing Address - Phone:513-290-2205
Mailing Address - Fax:
Practice Address - Street 1:15055 NW 27TH AVE
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-3365
Practice Address - Country:US
Practice Address - Phone:786-466-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH25982101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health