Provider Demographics
NPI:1104397041
Name:GOLD, CONRAD (MA, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:CONRAD
Middle Name:
Last Name:GOLD
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 WAUKAZOO AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-3125
Mailing Address - Country:US
Mailing Address - Phone:231-348-9148
Mailing Address - Fax:
Practice Address - Street 1:1500 SPRING STREET
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-3125
Practice Address - Country:US
Practice Address - Phone:231-347-1678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist