Healthcare Provider Details

I. General information

NPI: 1316609027
Provider Name (Legal Business Name): MANDY CONRAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2021
Last Update Date: 10/23/2021
Certification Date: 10/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 WAMPANOAG TRL
RIVERSIDE RI
02915-2232
US

IV. Provider business mailing address

110 ELM ST FL 3
PROVIDENCE RI
02903-4626
US

V. Phone/Fax

Practice location:
  • Phone: 401-649-4020
  • Fax:
Mailing address:
  • Phone: 401-649-4020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: