Provider Demographics
NPI:1023762622
Name:BURBANK, CONRAD (PSYD)
Entity type:Individual
Prefix:DR
First Name:CONRAD
Middle Name:
Last Name:BURBANK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3715 GALLOWAY ST APT D112
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-5604
Mailing Address - Country:US
Mailing Address - Phone:773-318-8866
Mailing Address - Fax:
Practice Address - Street 1:3715 GALLOWAY ST APT D112
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-5604
Practice Address - Country:US
Practice Address - Phone:773-318-8866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPSY-PSY-LIC-3564103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical