Provider Demographics
NPI:1750614079
Name:GORE, CANDICE YVONNE (LCAS)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:YVONNE
Last Name:GORE
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:YVONNE
Other - Last Name:GLOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCAS
Mailing Address - Street 1:4321 TILLSON ROAD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412
Mailing Address - Country:US
Mailing Address - Phone:770-722-4882
Mailing Address - Fax:
Practice Address - Street 1:1606 WELLINGTON AVE UNIT C
Practice Address - Street 2:COMMUNITY SUPPORT PROFESSIONALS,LLC
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7704
Practice Address - Country:US
Practice Address - Phone:910-799-4505
Practice Address - Fax:910-799-4345
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1759101YA0400X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1759OtherNORTH CAROLINA SUBSTANCE ABUSE PRACTICE BOARD