Provider Demographics
NPI:1114389301
Name:TILLERY, CANDACE LYNN (LMSW, CAADC, SAP)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:LYNN
Last Name:TILLERY
Suffix:
Gender:F
Credentials:LMSW, CAADC, SAP
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:LYNN
Other - Last Name:BUCKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW, CAADC, SAP
Mailing Address - Street 1:3721 W MICHIGAN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-3600
Mailing Address - Country:US
Mailing Address - Phone:517-515-6176
Mailing Address - Fax:
Practice Address - Street 1:3721 W MICHIGAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-3600
Practice Address - Country:US
Practice Address - Phone:517-515-6176
Practice Address - Fax:517-515-6176
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-25
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-03445101YA0400X
103K00000X, 1041C0700X
MI68010994671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst