Healthcare Provider Details

I. General information

NPI: 1679880991
Provider Name (Legal Business Name): WILLIAM T CONRAD MA.ED.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6218 S 7TH ST
PHOENIX AZ
85042-4211
US

IV. Provider business mailing address

6218 S 7TH ST
PHOENIX AZ
85042-4211
US

V. Phone/Fax

Practice location:
  • Phone: 602-243-4866
  • Fax:
Mailing address:
  • Phone: 602-243-4866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4303899
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: