Healthcare Provider Details

I. General information

NPI: 1497264014
Provider Name (Legal Business Name): JOSEPH GERARD CONRAD LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 09/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 CHURCH STREET
NEW PRESTON CT
06777
US

IV. Provider business mailing address

17 CHURCH ST
NEW PRESTON CT
06777-1502
US

V. Phone/Fax

Practice location:
  • Phone: 203-528-7852
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number01212
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: