Provider Demographics
NPI:1922128487
Name:ALICE SUE CONRAD
Entity Type:Organization
Organization Name:ALICE SUE CONRAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-875-6751
Mailing Address - Street 1:1407 SAINT ANDREW ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-2327
Mailing Address - Country:US
Mailing Address - Phone:573-875-6751
Mailing Address - Fax:573-442-2086
Practice Address - Street 1:1407 SAINT ANDREW ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-2327
Practice Address - Country:US
Practice Address - Phone:573-875-6751
Practice Address - Fax:573-442-2086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO8001661320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities