Provider Demographics
NPI:1023363199
Name:SIMMONS, SYDNIE KIM (MED)
Entity Type:Individual
Prefix:
First Name:SYDNIE
Middle Name:KIM
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 S CARMEL ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2344
Mailing Address - Country:US
Mailing Address - Phone:231-775-6517
Mailing Address - Fax:231-775-6587
Practice Address - Street 1:805 S CARMEL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2344
Practice Address - Country:US
Practice Address - Phone:231-775-6517
Practice Address - Fax:231-775-6587
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015181103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical