Healthcare Provider Details

I. General information

NPI: 1134212350
Provider Name (Legal Business Name): KAYLA JAN CONRAD PHD LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 FULLER RD # 116A
ANN ARBOR MI
48105-2303
US

IV. Provider business mailing address

1214 BIRK AVE
ANN ARBOR MI
48103-5306
US

V. Phone/Fax

Practice location:
  • Phone: 248-646-6659
  • Fax: 248-642-8645
Mailing address:
  • Phone: 248-229-2123
  • Fax: 734-845-3235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberL973160
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: