Provider Demographics
NPI:1154861474
Name:NIMS, THERESA VALENTINE X
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:VALENTINE
Last Name:NIMS
Suffix:X
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:VALENTINE
Other - Last Name:HARDIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1210 SW 136TH ST
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1214
Mailing Address - Country:US
Mailing Address - Phone:206-257-6902
Mailing Address - Fax:206-257-6825
Practice Address - Street 1:1210 SW 136TH ST
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1214
Practice Address - Country:US
Practice Address - Phone:206-257-6902
Practice Address - Fax:206-257-6825
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00005076101YM0800X
WACP00002592101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health