MEDICARE: MR. PHILIP CONRAD LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	52003	TX

General Provider Information

NPI Number	:	1053372979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PHILIP CONRAD LCSW

Provider Business Mailing Address
First Line	:	6115 SAINTSBURY DR
Second Line	:	NO 25
City	:	THE COLONY
State	:	TX
Zip	:	75056-5388
Country	:	US
Telephone Number	:	469-358-1060
Fax Number	:

Provider Business Practice Location Address
First Line	:	6115 SAINTSBURY DRIVE
Second Line	:	NO 25
City	:	THE COLONY
State	:	TX
Zip	:	75056-5212
Country	:	US
Telephone Number	:	469-358-1060
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2006
Last Update Date	:	12/02/2011

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