Provider Demographics
NPI:1407120454
Name:SIMON, THERESA L (CPTA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:SIMON
Suffix:
Gender:F
Credentials:CPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67487-9159
Mailing Address - Country:US
Mailing Address - Phone:785-461-5417
Mailing Address - Fax:
Practice Address - Street 1:622 N EDGEMOOR ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-3602
Practice Address - Country:US
Practice Address - Phone:316-686-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01316225200000X
KS62-1626490172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No172V00000XOther Service ProvidersCommunity Health Worker