Healthcare Provider Details

I. General information

NPI: 1467362822
Provider Name (Legal Business Name): THEODORE CATANZARO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10590 WAYZATA BLVD STE 160
MINNETONKA MN
55305-5531
US

IV. Provider business mailing address

200 NATHAN LN N APT 312
PLYMOUTH MN
55441-6480
US

V. Phone/Fax

Practice location:
  • Phone: 651-505-3273
  • Fax:
Mailing address:
  • Phone: 651-505-3273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number41378
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: