Surdy Psychological Services LLC

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

LP3385 Issued in MN

Legal business name

SURDY PSYCHOLOGICAL SERVICES LLC

Doing business as

Mending Roots

Practice address

1227 Caledonia St
Mankato, MN 56001-4329

Phone

(507) 388-8874

Fax

(507) 625-4807

NPI assigned

Feb 10, 2017

Last updated

Jan 22, 2025By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Theodore Surdy, PH.DNPI 1063463347

Title

Ceo

Phone

(507) 388-8874

Specialties & licenses 1

Addresses

Other identifiers 5

Other names 1

• Mending Roots Doing business as

Medicare fee-for-service enrollment

Enrolled in MN

Enrollment records 1

Locations

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Theodore Nash Surdy, LPCC

  • Mental Health Counselor
  • Mankato, MN
  • NPI 1629663919
  Medicare reassignment Care Compare group NPD
• Taylor Wester, MS, LPCC

  • Mental Health Counselor
  • Mankato, MN
  • NPI 1912582032
  Medicare reassignment Care Compare group NPD
• Stephen Lee Larson Jr., LICSW, MSW

  • Clinical Social Worker
  • Mankato, MN
  • NPI 1659618650
  Medicare reassignment NPD
• Theodore Surdy, PHD LP

  • Clinical Psychologist
  • Mankato, MN
  • NPI 1063463347
  NPD Authorized official
• Christina Noel Mellenberger

  • Mental Health Counselor
  • Henderson, TN
  • NPI 1538633839

  MN

  Medicare reassignment
• Baily Kaas, LADC

  • Addiction (Substance Use Disorder) Counselor
  • Mankato, MN
  • NPI 1306656848
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1486684800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1737504000000",
    "number": "1225576127",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1227 CALEDONIA ST",
            "city": "MANKATO",
            "state": "MN",
            "postal_code": "560014329",
            "telephone_number": "507-388-8874",
            "fax_number": "507-625-4807"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1227 CALEDONIA ST",
            "city": "MANKATO",
            "state": "MN",
            "postal_code": "560014329",
            "telephone_number": "507-388-8874",
            "fax_number": "507-625-4807"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SURDY PSYCHOLOGICAL SERVICES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-02-10",
        "last_updated": "2025-01-22",
        "certification_date": "2025-01-22",
        "status": "A",
        "authorized_official_last_name": "SURDY",
        "authorized_official_first_name": "THEODORE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "507-388-8874",
        "authorized_official_credential": "PH.D"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "MN",
            "license": "LP3385",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HEALTH PARTNERS",
            "identifier": "HP28628",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED",
            "identifier": "114945",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UCARE MINNESOTA",
            "identifier": "114945",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BXBS",
            "identifier": "06T04SU",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "497823400",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mending Roots",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Annette Nichole Sullivan, M.D.
• Kara Marie Sullivan, MD
• Supervalu Pharmacies Inc (Cub Pharmacy)
• Supervalu Pharmacies Inc (Cub Pharmacy)
• Maci Marie Surat
• Taryn Surdy, LAMFT
• Theodore Surdy, PHD LP
• Theodore Nash Surdy, LPCC
• Fiona Swanson, LICSW
• Gene Earl Swanson, M.D.

• Clinical Psychologist in Mankato, MN
• Providers in Mankato, MN by specialty
• Clinical Psychologist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 22, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.