Healthcare Provider Details

I. General information

NPI: 1487578555
Provider Name (Legal Business Name): MARY CONDRA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2916 PEACH BLOSSOM DR STE 104
JEFFERSONVILLE IN
47130-8380
US

IV. Provider business mailing address

3006 EASTPOINT PKWY
LOUISVILLE KY
40223-4185
US

V. Phone/Fax

Practice location:
  • Phone: 812-202-6144
  • Fax:
Mailing address:
  • Phone: 502-795-0773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-2837935
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: