1467480343 NPI number — SHANNON B SIMMONS MS, LPC

Table of content: SHANNON B SIMMONS MS, LPC (NPI 1467480343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467480343 NPI number — SHANNON B SIMMONS MS, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMMONS
Provider First Name:
SHANNON
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467480343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 W HICKORY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEVADA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64772-2144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-549-0943
Provider Business Mailing Address Fax Number:
417-667-2281

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
815 S ASH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEVADA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64772-3222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-667-8352
Provider Business Practice Location Address Fax Number:
417-667-9216
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  2006005029 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 490620606 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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