Provider Demographics
NPI:1972739324
Name:CONRAD, RONALD GLENN I (PTA)
Entity type:Individual
Prefix:MR
First Name:RONALD
Middle Name:GLENN
Last Name:CONRAD
Suffix:I
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53563-1546
Mailing Address - Country:US
Mailing Address - Phone:608-868-5465
Mailing Address - Fax:
Practice Address - Street 1:11971 WAGON WHEEL RD
Practice Address - Street 2:
Practice Address - City:ROCKTON
Practice Address - State:IL
Practice Address - Zip Code:61072-3322
Practice Address - Country:US
Practice Address - Phone:815-624-2615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-29
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160-003223225200000X
WI930-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant