Healthcare Provider Details

I. General information

NPI: 1548826316
Provider Name (Legal Business Name): ELIZABETH CONROY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 05/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

634 N MAIN ST
O FALLON IL
62269-3751
US

IV. Provider business mailing address

634 NORTH MAIN STREET
O'FALLON IL
62269
US

V. Phone/Fax

Practice location:
  • Phone: 618-690-0068
  • Fax:
Mailing address:
  • Phone: 618-690-0068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: