Provider Demographics
NPI:1003923889
Name:INES, THEODORE MICHAEL (PHD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:MICHAEL
Last Name:INES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:TED
Other - Middle Name:
Other - Last Name:INES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2215 BURDETT AVE
Mailing Address - Street 2:BEHAVIORAL HEALTH DEPT
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2466
Mailing Address - Country:US
Mailing Address - Phone:518-271-3300
Mailing Address - Fax:
Practice Address - Street 1:2215 BURDETT AVE
Practice Address - Street 2:BEHAVIORAL HEALTH DEPT
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2466
Practice Address - Country:US
Practice Address - Phone:518-271-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016782103T00000X
FLPY4748103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist