Provider Demographics
NPI:1083772313
Name:PAGE, THEODORE RAYMOND (LICSW)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:RAYMOND
Last Name:PAGE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 OHIO ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-2656
Mailing Address - Country:US
Mailing Address - Phone:651-278-1771
Mailing Address - Fax:
Practice Address - Street 1:491 OHIO ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2656
Practice Address - Country:US
Practice Address - Phone:651-278-1771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN150791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical