Provider Demographics
NPI:1760230734
Name:CONRAD, OTTAWL DOUGLAS (PSS)
Entity type:Individual
Prefix:
First Name:OTTAWL
Middle Name:DOUGLAS
Last Name:CONRAD
Suffix:
Gender:M
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:859-813-5394
Practice Address - Street 1:209 DAVIS RD
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9549
Practice Address - Country:US
Practice Address - Phone:859-498-6574
Practice Address - Fax:859-498-7325
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-07
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist