Provider Demographics
NPI:1033897392
Name:SIMON, ANTHONY
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9715 NW 123RD TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-2950
Mailing Address - Country:US
Mailing Address - Phone:786-780-9294
Mailing Address - Fax:
Practice Address - Street 1:9715 NW 123RD TER
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-2950
Practice Address - Country:US
Practice Address - Phone:786-780-9294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-281651106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty