Provider Demographics
NPI:1750174850
Name:CONWAY, DONALD THOMAS
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:THOMAS
Last Name:CONWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16748 ROUGH AND READY RD
Mailing Address - Street 2:
Mailing Address - City:FAIR BLUFF
Mailing Address - State:NC
Mailing Address - Zip Code:28439-9556
Mailing Address - Country:US
Mailing Address - Phone:843-356-8023
Mailing Address - Fax:
Practice Address - Street 1:730 MAIN ST # 230
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-3030
Practice Address - Country:US
Practice Address - Phone:813-763-5469
Practice Address - Fax:813-441-8362
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-22
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRBT-25-438101106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician