Provider Demographics
NPI:1033454756
Name:SIMMONS, HEATHER MARIE (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5229
Mailing Address - Country:US
Mailing Address - Phone:912-283-0777
Mailing Address - Fax:
Practice Address - Street 1:303 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5229
Practice Address - Country:US
Practice Address - Phone:912-283-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008050235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003130506BMedicaid