Provider Demographics
NPI:1528321098
Name:ERVIN, CANDACE GILES (MD)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:GILES
Last Name:ERVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:LASHUN
Other - Last Name:GILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3600 DALLAS HIGHWAY STE 230 PMB 113
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064
Mailing Address - Country:US
Mailing Address - Phone:470-398-1771
Mailing Address - Fax:470-617-7350
Practice Address - Street 1:1300 RIDENOUR BLVD NW STE 108
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4528
Practice Address - Country:US
Practice Address - Phone:470-398-1771
Practice Address - Fax:470-617-7350
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2023-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA777422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty