Provider Demographics
NPI:1821221490
Name:CONRAD, MICHAEL DEAN (PC/CR)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DEAN
Last Name:CONRAD
Suffix:
Gender:M
Credentials:PC/CR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6370 WISE AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7350
Mailing Address - Country:US
Mailing Address - Phone:330-493-0083
Mailing Address - Fax:330-493-3689
Practice Address - Street 1:6370 WISE AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7350
Practice Address - Country:US
Practice Address - Phone:330-493-0083
Practice Address - Fax:330-493-3689
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0500075101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH547Medicaid
OH215-01OtherJOB AND FAMILY SERVICES
OH547Medicaid