Provider Demographics
NPI:1932286085
Name:KIMBERLY ANNE CONRAD PLC
Entity Type:Organization
Organization Name:KIMBERLY ANNE CONRAD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:SED
Authorized Official - Phone:319-240-0944
Mailing Address - Street 1:25271 JOHNSONS MILL RD
Mailing Address - Street 2:
Mailing Address - City:WAUCOMA
Mailing Address - State:IA
Mailing Address - Zip Code:52171-7137
Mailing Address - Country:US
Mailing Address - Phone:219-240-0944
Mailing Address - Fax:563-776-4061
Practice Address - Street 1:100 1ST AVE SW
Practice Address - Street 2:
Practice Address - City:WAUCOMA
Practice Address - State:IA
Practice Address - Zip Code:52171-9705
Practice Address - Country:US
Practice Address - Phone:563-776-4060
Practice Address - Fax:563-776-4061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA351029101YS0200X
IA06449251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0470138Medicaid
IA1012617Medicaid