Provider Demographics
NPI:1689330847
Name:FERNSTROM, TYSON RAY (DPT)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:RAY
Last Name:FERNSTROM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W HIGHWAY 290 STE B300
Mailing Address - Street 2:
Mailing Address - City:DRIPPING SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78620-4051
Mailing Address - Country:US
Mailing Address - Phone:512-858-5191
Mailing Address - Fax:512-858-5194
Practice Address - Street 1:800 W HIGHWAY 290 STE B300
Practice Address - Street 2:
Practice Address - City:DRIPPING SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:78620-4051
Practice Address - Country:US
Practice Address - Phone:512-858-5191
Practice Address - Fax:512-858-5194
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1354852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty