Provider Demographics
NPI:1831275056
Name:CONRAD, SELBY MARTIN (PHD)
Entity type:Individual
Prefix:DR
First Name:SELBY
Middle Name:MARTIN
Last Name:CONRAD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOPPIN STREET, CORO WEST, SUITE 204
Mailing Address - Street 2:BRADLEY HASBRO CHILDREN'S RESEARCH CENTER
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903
Mailing Address - Country:US
Mailing Address - Phone:401-444-6560
Mailing Address - Fax:
Practice Address - Street 1:1 HOPPIN STREET, CORO WEST, SUITE 204
Practice Address - Street 2:BRADLEY HASBRO CHILDREN'S RESEARCH CENTER
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903
Practice Address - Country:US
Practice Address - Phone:401-444-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01273103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist