Provider Demographics
NPI:1457610131
Name:SIMON, THELMA ROSE (LADC, BSW)
Entity Type:Individual
Prefix:
First Name:THELMA
Middle Name:ROSE
Last Name:SIMON
Suffix:
Gender:F
Credentials:LADC, BSW
Other - Prefix:
Other - First Name:THELMA
Other - Middle Name:ROSE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC, BSW
Mailing Address - Street 1:9714 MARGARITA STREET
Mailing Address - Street 2:
Mailing Address - City:MCDERMITT
Mailing Address - State:NV
Mailing Address - Zip Code:89421
Mailing Address - Country:US
Mailing Address - Phone:775-532-8522
Mailing Address - Fax:775-532-8204
Practice Address - Street 1:112 NORTH RESERVATION ROAD
Practice Address - Street 2:FORT MCDERMITT INDIAN HEALTH SERVICE
Practice Address - City:MCDERMITT
Practice Address - State:NV
Practice Address - Zip Code:89421
Practice Address - Country:US
Practice Address - Phone:775-532-8522
Practice Address - Fax:775-532-8024
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV767-L101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)