Healthcare Provider Details

I. General information

NPI: 1760592067
Provider Name (Legal Business Name): CAROL ANN CONRAD III EDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 S WARSAW ST
NAUVOO IL
62354-1311
US

IV. Provider business mailing address

680 S WARSAW ST
NAUVOO IL
62354-1311
US

V. Phone/Fax

Practice location:
  • Phone: 208-591-8338
  • Fax:
Mailing address:
  • Phone: 208-591-8338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071.011231
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: