Provider Demographics
NPI:1861418253
Name:DELAET, THEODORE JAMES (PHD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:JAMES
Last Name:DELAET
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6608 S 107TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68127-4558
Mailing Address - Country:US
Mailing Address - Phone:402-331-3944
Mailing Address - Fax:402-333-8210
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE236103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-083617826Medicaid
NE273790Medicare ID - Type Unspecified