Provider Demographics
NPI:1790263424
Name:GANT, CANDICE MARIE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:MARIE
Last Name:GANT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 E 71ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-2000
Mailing Address - Country:US
Mailing Address - Phone:708-292-8730
Mailing Address - Fax:773-692-9477
Practice Address - Street 1:1817 E 71ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-2000
Practice Address - Country:US
Practice Address - Phone:708-292-8730
Practice Address - Fax:773-692-9477
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0243161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty