Provider Demographics
NPI:1861567513
Name:THEISZ, KATE (PSYD)
Entity type:Individual
Prefix:DR
First Name:KATE
Middle Name:
Last Name:THEISZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20934 OGDEN ST NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-8909
Mailing Address - Country:US
Mailing Address - Phone:612-242-9291
Mailing Address - Fax:
Practice Address - Street 1:657 MAIN ST NW STE 214
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1579
Practice Address - Country:US
Practice Address - Phone:763-412-1994
Practice Address - Fax:763-412-1994
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4647103TC0700X
MNLP4647103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty