Provider Demographics
NPI:1821467218
Name:MARLYS A CONRAD PHD LLC
Entity Type:Organization
Organization Name:MARLYS A CONRAD PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARLYS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-624-7446
Mailing Address - Street 1:918 MICHIGAN AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-1494
Mailing Address - Country:US
Mailing Address - Phone:847-624-7446
Mailing Address - Fax:
Practice Address - Street 1:918 MICHIGAN AVE
Practice Address - Street 2:APT 1
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-1494
Practice Address - Country:US
Practice Address - Phone:847-624-7446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071003676101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071003676OtherILLINOIS LICENSE