Provider Demographics
NPI:1003506908
Name:BURGHARDT, CONRAD JAMES
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:JAMES
Last Name:BURGHARDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 SHERMAN AVE APT 301
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3267
Mailing Address - Country:US
Mailing Address - Phone:847-749-8796
Mailing Address - Fax:
Practice Address - Street 1:400 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:IL
Practice Address - Zip Code:60043-1001
Practice Address - Country:US
Practice Address - Phone:847-919-9096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker