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General NPI Number Information
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NPI Number | 1407120454
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Entity Type | Individual
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Provider Name | THERESA L SIMON CPTA
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Gender | Female
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Dates
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Enumeration Date | 03/07/2012
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Last Update Date | 09/01/2020
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Provider Practice Location Address
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Address Line | 622 N EDGEMOOR ST
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City | WICHITA
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State | KS
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Zip | 67208-3602
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Country | US
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Telephone | 316-686-5100
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Fax |
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Provider Business Mailing Address
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Address Line | 509 GROVE ST
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City | WAKEFIELD
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State | KS
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Zip | 67487-9159
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Country | US
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Telephone | 785-461-5417
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 14-01316
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | 62-1626490
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License Number State | KS
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