=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912521360
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDICE CAVETT MA, LLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2020
-----------------------------------------------------
Last Update Date | 04/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2401 S LINDEN RD
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48532-9800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-395-3223
-----------------------------------------------------
Fax | 248-620-6405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6549 TOWN CENTER DR STE A
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48346-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-395-3223
-----------------------------------------------------
Fax | 248-620-6405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6361000496
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 6361000496
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6361000496
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------