Provider Demographics
NPI:1114259595
Name:ATTAWAY, CANDACE (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:ATTAWAY
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:
Other - Last Name:ADESZKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT, OTR/L
Mailing Address - Street 1:2522 W SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-5255
Mailing Address - Country:US
Mailing Address - Phone:815-272-1027
Mailing Address - Fax:
Practice Address - Street 1:3403 RAVINIA CIR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-3145
Practice Address - Country:US
Practice Address - Phone:815-272-1027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008926225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist