Provider Demographics
NPI:1003562695
Name:SIMMONS, MICHELLE REYNOLDS
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:REYNOLDS
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 575
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:76050-0575
Mailing Address - Country:US
Mailing Address - Phone:817-933-2772
Mailing Address - Fax:
Practice Address - Street 1:1014 FERRIS AVE STE 1045
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2590
Practice Address - Country:US
Practice Address - Phone:817-933-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79752101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional