Healthcare Provider Details

I. General information

NPI: 1407488562
Provider Name (Legal Business Name): MARC CONRAD TY TENTATIVA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3951 ALMA RD STE 201
MCKINNEY TX
75070
US

IV. Provider business mailing address

15410 S MOUNTAIN PKWY STE 112
PHOENIX AZ
85044-6691
US

V. Phone/Fax

Practice location:
  • Phone: 469-456-4155
  • Fax:
Mailing address:
  • Phone: 480-689-5534
  • Fax: 480-706-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1328172
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1328172
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: