Provider Demographics
NPI:1801189600
Name:KATUSKY, TERRY ROSE (LADC)
Entity Type:Individual
Prefix:MS
First Name:TERRY
Middle Name:ROSE
Last Name:KATUSKY
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5564 129TH DR N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-8462
Mailing Address - Country:US
Mailing Address - Phone:651-216-0305
Mailing Address - Fax:654-489-6458
Practice Address - Street 1:135 COLORADO ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2244
Practice Address - Country:US
Practice Address - Phone:651-489-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301583101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)