Provider Demographics
NPI:1114067618
Name:SIMS, GREGORY M (PHD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:M
Last Name:SIMS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:GREGORY
Other - Middle Name:KNOX
Other - Last Name:SIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95415
Mailing Address - Country:US
Mailing Address - Phone:707-895-2304
Mailing Address - Fax:707-895-2537
Practice Address - Street 1:18025 BLATTNER ROAD
Practice Address - Street 2:
Practice Address - City:PHILO
Practice Address - State:CA
Practice Address - Zip Code:95466
Practice Address - Country:US
Practice Address - Phone:707-895-2304
Practice Address - Fax:707-895-2537
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA LIC NO PSY4045103T00000X
CAPSY4045103TC0700X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL40451Medicaid
CAPSY4045AMedicare ID - Type Unspecified
CA00PL40451Medicaid