MEDICARE: BEVERLY CONRAD

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	235Z00000X	Speech-Language Pathologist	2202001340	VA

General Provider Information

NPI Number	:	1508275660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVERLY CONRAD

Provider Business Mailing Address
First Line	:	12253 SEAFORD CT
Second Line	:
City	:	LAKE RIDGE
State	:	VA
Zip	:	22192-2356
Country	:	US
Telephone Number	:	425-205-0220
Fax Number	:

Provider Business Practice Location Address
First Line	:	12253 SEAFORD CT
Second Line	:
City	:	LAKE RIDGE
State	:	VA
Zip	:	22192-2356
Country	:	US
Telephone Number	:	425-205-0220
Fax Number	:

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

Provider Enumeration Date	:	08/03/2014
Last Update Date	:	08/03/2014

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Directions to “ BEVERLY CONRAD ” Practice Location

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