Provider Demographics
NPI:1225023856
Name:KILLACKEY, CANDIE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:CANDIE
Middle Name:
Last Name:KILLACKEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VT
Mailing Address - Zip Code:05454-0011
Mailing Address - Country:US
Mailing Address - Phone:978-526-4438
Mailing Address - Fax:
Practice Address - Street 1:350 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:ST. ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478
Practice Address - Country:US
Practice Address - Phone:802-526-4438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10179161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA470068OtherTUFTS HEALTH PLAN
MA470068OtherTUFTS HEALTH PLAN
MAP08409OtherBLUE CROSS BLUE SHIELD OF