Healthcare Provider Details

I. General information

NPI: 1932286085
Provider Name (Legal Business Name): KIMBERLY ANNE CONRAD PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 1ST AVE SW
WAUCOMA IA
52171-9705
US

IV. Provider business mailing address

25271 JOHNSONS MILL RD
WAUCOMA IA
52171-7137
US

V. Phone/Fax

Practice location:
  • Phone: 563-776-4060
  • Fax: 563-776-4061
Mailing address:
  • Phone: 219-240-0944
  • Fax: 563-776-4061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number351029
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number06449
License Number StateIA

VIII. Authorized Official

Name: KIMBERLY ANNE CONRAD
Title or Position: DIRECTOR
Credential: SED
Phone: 319-240-0944