Provider Demographics
NPI:1225576127
Name:SURDY PSYCHOLOGICAL SERVICES LLC
Entity Type:Organization
Organization Name:SURDY PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:SURDY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:507-388-8874
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:507-625-4807
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:507-625-4807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-10
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3385103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN114945OtherUCARE MINNESOTA
MNHP28628OtherHEALTH PARTNERS
MN497823400Medicaid
MN06T04SUOtherBXBS
MN114945OtherUNITED
MNH100373084Medicare PIN