Healthcare Provider Details

I. General information

NPI: 1558791103
Provider Name (Legal Business Name): MELISSA CONRAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22950 NORTHLINE RD
TAYLOR MI
48180-4696
US

IV. Provider business mailing address

22950 NORTHLINE RD
TAYLOR MI
48180-4696
US

V. Phone/Fax

Practice location:
  • Phone: 734-287-1230
  • Fax:
Mailing address:
  • Phone: 734-287-1230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202007291
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: