Provider Demographics
NPI:1194022590
Name:PACKER, CANDICE (CSW)
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:PACKER
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2100
Mailing Address - Country:US
Mailing Address - Phone:801-528-3247
Mailing Address - Fax:801-753-0409
Practice Address - Street 1:130 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2100
Practice Address - Country:US
Practice Address - Phone:801-528-3247
Practice Address - Fax:801-753-0409
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7744469-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1770721300Medicaid