Provider Demographics
NPI:1124556931
Name:CONNELL, CANDIS MIAH (PSYD)
Entity type:Individual
Prefix:DR
First Name:CANDIS
Middle Name:MIAH
Last Name:CONNELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:CANDIS
Other - Middle Name:
Other - Last Name:CORNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:13515 LAKE TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33637-1003
Mailing Address - Country:US
Mailing Address - Phone:813-919-9152
Mailing Address - Fax:
Practice Address - Street 1:13515 LAKE TERRACE LN
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33637-1003
Practice Address - Country:US
Practice Address - Phone:813-919-9152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005647103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist