Provider Demographics
NPI:1710194923
Name:CONRAD, SARA M (COTA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:M
Last Name:CONRAD
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W860 KIEL RD
Mailing Address - Street 2:
Mailing Address - City:NEW HOLSTEIN
Mailing Address - State:WI
Mailing Address - Zip Code:53061-9412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3431 N 13TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-2938
Practice Address - Country:US
Practice Address - Phone:920-457-5046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1987-027224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41044800Medicaid