Provider Demographics
NPI:1548517493
Name:WALTRIP, CANDICE (PSYD)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:
Last Name:WALTRIP
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 E FLOWERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8148
Mailing Address - Country:US
Mailing Address - Phone:801-613-1048
Mailing Address - Fax:
Practice Address - Street 1:721 N 530 E
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-4105
Practice Address - Country:US
Practice Address - Phone:801-613-1048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9159603-2501103T00000X, 103TC0700X, 103TF0200X, 103TP2701X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling