Provider Demographics
NPI:1235955063
Name:CANDID SPACE LLC
Entity type:Organization
Organization Name:CANDID SPACE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATRICK-WADE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:847-474-9755
Mailing Address - Street 1:1130 S CANAL ST # 1054
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4907
Mailing Address - Country:US
Mailing Address - Phone:847-474-9755
Mailing Address - Fax:
Practice Address - Street 1:1130 S CANAL ST # 1054
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4907
Practice Address - Country:US
Practice Address - Phone:847-474-9755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty