Provider Demographics
NPI:1023670262
Name:CHILD-ILLUM, CANDICE JANE (CSW, MSW)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:JANE
Last Name:CHILD-ILLUM
Suffix:
Gender:F
Credentials:CSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3149 N HIGHWAY 89 STE 200
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VIEW
Mailing Address - State:UT
Mailing Address - Zip Code:84404-1202
Mailing Address - Country:US
Mailing Address - Phone:801-782-6600
Mailing Address - Fax:
Practice Address - Street 1:3149 N HIGHWAY 89 STE 200
Practice Address - Street 2:
Practice Address - City:PLEASANT VIEW
Practice Address - State:UT
Practice Address - Zip Code:84404-1202
Practice Address - Country:US
Practice Address - Phone:801-782-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11187387-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical