Provider Demographics
NPI:1942656905
Name:MCCANN, THEODORE SCOTT
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:SCOTT
Last Name:MCCANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 BROADWAY ST NE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2627
Mailing Address - Country:US
Mailing Address - Phone:651-357-0307
Mailing Address - Fax:
Practice Address - Street 1:1915 BROADWAY ST NE
Practice Address - Street 2:SUITE 110
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2627
Practice Address - Country:US
Practice Address - Phone:651-357-0307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist