Provider Demographics
NPI:1508275660
Name:CONRAD, BEVERLY
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12253 SEAFORD CT
Mailing Address - Street 2:
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2356
Mailing Address - Country:US
Mailing Address - Phone:425-205-0220
Mailing Address - Fax:
Practice Address - Street 1:12253 SEAFORD CT
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2356
Practice Address - Country:US
Practice Address - Phone:425-205-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-03
Last Update Date:2014-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202001340235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist