Provider Demographics
NPI:1447742838
Name:EAST, THEODORE JOHN (MSMFT)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:JOHN
Last Name:EAST
Suffix:
Gender:M
Credentials:MSMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W7163 DEERTAIL RD
Mailing Address - Street 2:
Mailing Address - City:LADYSMITH
Mailing Address - State:WI
Mailing Address - Zip Code:54848-9344
Mailing Address - Country:US
Mailing Address - Phone:715-403-1688
Mailing Address - Fax:
Practice Address - Street 1:108 W 2ND ST N
Practice Address - Street 2:
Practice Address - City:LADYSMITH
Practice Address - State:WI
Practice Address - Zip Code:54848-1338
Practice Address - Country:US
Practice Address - Phone:715-532-9771
Practice Address - Fax:715-532-9774
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI235-124106H00000X
WI3364-123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist