MEDICARE: DR. NYDIA CONRAD COUNSELING & PSYCHOLOGICAL ASSESSMENT SERVICES, LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	8091	FL

General Provider Information

NPI Number	:	1548573256
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. NYDIA CONRAD COUNSELING & PSYCHOLOGICAL ASSESSMENT SERVICES, LLC

Provider Business Mailing Address
First Line	:	3848 FLATIRON LOOP UNIT 101
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33544-7825
Country	:	US
Telephone Number	:	813-480-6427
Fax Number	:	813-788-3492

Provider Business Practice Location Address
First Line	:	3848 FLATIRON LOOP UNIT 101
Second Line	:
City	:	WESLEY CHAPEL
State	:	FL
Zip	:	33544-7825
Country	:	US
Telephone Number	:	813-480-6427
Fax Number	:	813-788-3492

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	DR. NYDIA CONRAD
Credential	:	PSYD
Telephone Number	:	813-480-6427

Provider Enumeration Date	:	07/22/2010
Last Update Date	:	12/02/2010

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