Healthcare Provider Details

I. General information

NPI: 1053372979
Provider Name (Legal Business Name): PHILIP CONRAD LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 12/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6115 SAINTSBURY DRIVE NO 25
THE COLONY TX
75056-5212
US

IV. Provider business mailing address

6115 SAINTSBURY DR NO 25
THE COLONY TX
75056-5388
US

V. Phone/Fax

Practice location:
  • Phone: 469-358-1060
  • Fax:
Mailing address:
  • Phone: 469-358-1060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number52003
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: