Basic Information
| Provider Information | |||||||||
| NPI: | 1124124490 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONRAD | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 957 SAINT JOSEPH ST | ||||||||
| Address2: | |||||||||
| City: | LORETTO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159407003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148864012 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1041 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | DUNCANSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 166351351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8146963873 | ||||||||
| FaxNumber: | 8146963877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT009154E | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7735639 | 01 | PA | AETNA NON-HMO | OTHER | 259359 | 01 | PA | HEALTH AMER/HEALTH ASSUR. | OTHER | CO1696441 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |