Basic Information
| Provider Information | |||||||||
| NPI: | 1093100745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONRAD | ||||||||
| FirstName: | ALEXIS | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 8116 RITCHIE HWY | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211226916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432612220 | ||||||||
| FaxNumber: | 4105445376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2015 | ||||||||
| LastUpdateDate: | 07/21/2016 | ||||||||
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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 | 225200000X | A4229 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | A4229 | 05 | MD | MEDICAID |