Provider Demographics
NPI:1396179602
Name:THEODORE J. DELAET, PH.D., P.C.
Entity Type:Organization
Organization Name:THEODORE J. DELAET, PH.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DELAET
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:402-333-8210
Mailing Address - Street 1:11414 W CENTER RD
Mailing Address - Street 2:SUITE 243
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-4486
Mailing Address - Country:US
Mailing Address - Phone:402-333-8210
Mailing Address - Fax:402-333-2298
Practice Address - Street 1:11414 W CENTER RD
Practice Address - Street 2:SUITE 243
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4486
Practice Address - Country:US
Practice Address - Phone:402-333-8210
Practice Address - Fax:402-333-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-23
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE236103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========26Medicaid
NER81409Medicare UPIN