Provider Demographics
NPI:1083065551
Name:SIMMONS, ELLEN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:SIMMONS
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 1:234 SHAWNEE CT
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-8702
Mailing Address - Country:US
Mailing Address - Phone:618-702-9163
Mailing Address - Fax:
Practice Address - Street 1:234 SHAWNEE CT
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-8702
Practice Address - Country:US
Practice Address - Phone:618-702-9163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-1960235Z00000X
IL146017381235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist