Provider Demographics
NPI:1619054764
Name:CONRAD, KIMBERLY ANNE (SED)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNE
Last Name:CONRAD
Suffix:
Gender:F
Credentials:SED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25271 JOHNSONS MILL RD
Mailing Address - Street 2:
Mailing Address - City:WAUCOMA
Mailing Address - State:IA
Mailing Address - Zip Code:52171-7137
Mailing Address - Country:US
Mailing Address - Phone:563-429-3591
Mailing Address - Fax:563-776-4061
Practice Address - Street 1:100 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:WAUCOMA
Practice Address - State:IA
Practice Address - Zip Code:52171-9705
Practice Address - Country:US
Practice Address - Phone:563-776-4060
Practice Address - Fax:563-776-4061
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA351029101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1012617Medicaid