Provider Demographics
NPI:1194134072
Name:GARDNER, CANDACE P (LMT)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:P
Last Name:GARDNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-4139
Mailing Address - Country:US
Mailing Address - Phone:815-459-3860
Mailing Address - Fax:815-459-3990
Practice Address - Street 1:10 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-4139
Practice Address - Country:US
Practice Address - Phone:815-459-3860
Practice Address - Fax:815-459-3990
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.016782225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist