Provider Demographics
NPI:1073753885
Name:SIMASEK, MARY GRACE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:SIMASEK
Suffix:
Gender:F
Credentials:MS, 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:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:NORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23127-0280
Mailing Address - Country:US
Mailing Address - Phone:757-566-3300
Mailing Address - Fax:757-566-8977
Practice Address - Street 1:150 POINT O'WOODS RD.
Practice Address - Street 2:
Practice Address - City:WILLLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-7052
Practice Address - Country:US
Practice Address - Phone:757-566-3300
Practice Address - Fax:757-566-8977
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202000725235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA45084OtherOPTIMA
VA49-6679OtherMEDICARE
VA194411OtherANTHEM
VA49-7850-1Medicaid