Provider Demographics
NPI:1700513215
Name:CONRAD, MICHELLA (MED,PSYD CANDIDATE)
Entity Type:Individual
Prefix:
First Name:MICHELLA
Middle Name:
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MED,PSYD CANDIDATE
Other - Prefix:
Other - First Name:MICHELLA
Other - Middle Name:
Other - Last Name:FANINI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, PSYD CANDIDAT
Mailing Address - Street 1:4119 MONTROSE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-4963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4119 MONTROSE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77006-4963
Practice Address - Country:US
Practice Address - Phone:512-956-6463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1898175Medicaid