Provider Demographics
NPI:1861518235
Name:CONRAD, ELISA S (MA, LCPC)
Entity type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:S
Last Name:CONRAD
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9112 SEWARD ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-7921
Mailing Address - Country:US
Mailing Address - Phone:774-573-1512
Mailing Address - Fax:
Practice Address - Street 1:604 S FREDERICK AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1275
Practice Address - Country:US
Practice Address - Phone:774-573-1512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52859106H00000X
225400000X
MDLC3301101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner