Provider Demographics
NPI:1780806943
Name:CONRAD, MARTHA LIECHTY (MSW)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:LIECHTY
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 E KERCHER RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-5325
Mailing Address - Country:US
Mailing Address - Phone:574-533-3633
Mailing Address - Fax:
Practice Address - Street 1:1400 HUDSON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-2023
Practice Address - Country:US
Practice Address - Phone:574-522-0104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33000041A171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator