Provider Demographics
NPI:1073701280
Name:CONIC, GEORGIA EDMONDSON (PHD)
Entity Type:Individual
Prefix:DR
First Name:GEORGIA
Middle Name:EDMONDSON
Last Name:CONIC
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 S JEFFERSON AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1267
Mailing Address - Country:US
Mailing Address - Phone:989-752-6628
Mailing Address - Fax:989-752-0895
Practice Address - Street 1:100 S JEFFERSON AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48607-1267
Practice Address - Country:US
Practice Address - Phone:989-752-6628
Practice Address - Fax:989-752-0895
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007381103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP02020001Medicare PIN