Provider Demographics
NPI:1992223036
Name:SPEIDEN, CANDICE N
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:N
Last Name:SPEIDEN
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 1:111 CROGHAN WAY
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175-9724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1239 WOODLAND DR STE 103
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2770
Practice Address - Country:US
Practice Address - Phone:270-506-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY104100000X
KY2549601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker