Provider Demographics
NPI:1063463347
Name:SURDY, THEODORE (PHD LP)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:
Last Name:SURDY
Suffix:
Gender:M
Credentials:PHD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 CALEDONIA ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4329
Mailing Address - Country:US
Mailing Address - Phone:507-388-8874
Mailing Address - Fax:507-685-4807
Practice Address - Street 1:1227 CALEDONIA ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4329
Practice Address - Country:US
Practice Address - Phone:507-388-8874
Practice Address - Fax:507-685-4807
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3385103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN06T04SUOtherBXBS
MN114945OtherUCARE MINNESOTA
FM114945OtherUNITED
MN497823400Medicaid
MNHP28628OtherHEALTH PARTNERS
MN114945OtherUCARE MINNESOTA