Provider Demographics
NPI:1174635213
Name:THEADO, KATHERINE M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:M
Last Name:THEADO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 W NORTH AVE
Mailing Address - Street 2:SUITE 495
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2425
Mailing Address - Country:US
Mailing Address - Phone:414-777-3178
Mailing Address - Fax:414-777-3204
Practice Address - Street 1:10400 W NORTH AVE
Practice Address - Street 2:SUITE 495
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2425
Practice Address - Country:US
Practice Address - Phone:414-777-3178
Practice Address - Fax:414-777-3204
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41005100Medicaid