Healthcare Provider Details

I. General information

NPI: 1114389301
Provider Name (Legal Business Name): CANDACE LYNN TILLERY LMSW, CAADC, SAP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CANDACE LYNN BUCKNER LMSW, CAADC, SAP

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3721 W MICHIGAN AVE STE 200
LANSING MI
48917-3600
US

IV. Provider business mailing address

3721 W MICHIGAN AVE STE 200
LANSING MI
48917-3600
US

V. Phone/Fax

Practice location:
  • Phone: 517-515-6176
  • Fax: 517-515-6176
Mailing address:
  • Phone: 517-515-6176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC-03445
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801099467
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: