Provider Demographics
NPI:1114485463
Name:COLES-SIMMONS, DETRIA (LPC)
Entity Type:Individual
Prefix:
First Name:DETRIA
Middle Name:
Last Name:COLES-SIMMONS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 HUDSON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07060-3702
Mailing Address - Country:US
Mailing Address - Phone:908-809-5579
Mailing Address - Fax:
Practice Address - Street 1:66 HUDSON AVE
Practice Address - Street 2:
Practice Address - City:NORTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07060-3702
Practice Address - Country:US
Practice Address - Phone:908-809-5579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH37PC00655900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health