Provider Demographics
NPI:1629663919
Name:SURDY, THEODORE NASH (LPCC)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:NASH
Last Name:SURDY
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 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 1:1207 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
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC02690101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health