1659340057 NPI number — DR. CAROL IVY SIMMONS PHD, LCSW-C

Table of content: DR. CAROL IVY SIMMONS PHD, LCSW-C (NPI 1659340057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659340057 NPI number — DR. CAROL IVY SIMMONS PHD, LCSW-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIMMONS
Provider First Name:
CAROL
Provider Middle Name:
IVY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD, LCSW-C
Provider Gender Code:
F

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:
1659340057
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1337
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLUP
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87305-1337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-722-1000
Provider Business Mailing Address Fax Number:
505-726-8557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7103 A ANTOCK PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPPER MARLBORO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-350-6377
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/16/2006

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: 1041C0700X , with the licence number:  10896 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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