Provider Demographics
NPI:1134499015
Name:THERESA SIMMONS
Entity Type:Organization
Organization Name:THERESA SIMMONS
Other - Org Name:DIVINE GAIA TRANSPERSONAL WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:BSW, MTP
Authorized Official - Phone:775-720-4284
Mailing Address - Street 1:11 CASTLE WAY
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-1932
Mailing Address - Country:US
Mailing Address - Phone:775-720-4284
Mailing Address - Fax:
Practice Address - Street 1:11 CASTLE WAY
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89706-1932
Practice Address - Country:US
Practice Address - Phone:775-720-4284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV=========Medicaid