Provider Demographics
NPI:1033960943
Name:RICHARDSON, SIMMONE SONG (CCOTA/L)
Entity Type:Individual
Prefix:
First Name:SIMMONE
Middle Name:SONG
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:CCOTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1537 74TH ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-2240
Mailing Address - Country:US
Mailing Address - Phone:505-203-5943
Mailing Address - Fax:
Practice Address - Street 1:984 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-2901
Practice Address - Country:US
Practice Address - Phone:718-701-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011481224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant