Provider Demographics
NPI:1306272323
Name:CONRAD, TERRY MANN (PT)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:MANN
Last Name:CONRAD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 ACADEMY RD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-4021
Mailing Address - Country:US
Mailing Address - Phone:662-268-8013
Mailing Address - Fax:662-268-8095
Practice Address - Street 1:513 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-4021
Practice Address - Country:US
Practice Address - Phone:662-268-8013
Practice Address - Fax:662-268-8095
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist