Provider Demographics
NPI:1659669109
Name:CONRAD, KATHERINE NEWMAN (MA)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:NEWMAN
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 N CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-3502
Mailing Address - Country:US
Mailing Address - Phone:803-435-2121
Mailing Address - Fax:803-435-8856
Practice Address - Street 1:14 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3502
Practice Address - Country:US
Practice Address - Phone:803-435-2121
Practice Address - Fax:803-435-8856
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5160101YP2500X
SC1730176934101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAD24CLMedicaid