| Doctor Name: | DR. THEODORE SURDY |
| NPI Number: | 1063463347 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PHD LP |
| License Number: | LP3385 |
| Business Practice Address: | 600 Reed St Suite 112 Mankato, MN - 560016410 |
| Business Phone Number: | 5076254060 |
| Business Fax Number: | 5076253915 |
| Mailing Address: | 16200 560th Ln, GOOD THUNDER |
| State: | MN |
| Postal Code: | 560372199 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 05/12/2006 |
| NPI Last Update Date: | 10/14/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | LP3385 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |