Provider Demographics
NPI:1114662202
Name:SIMON, BRANDY SUE
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:SUE
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 SOUTHGATE PKWY
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-3024
Mailing Address - Country:US
Mailing Address - Phone:740-781-0320
Mailing Address - Fax:
Practice Address - Street 1:1750 SOUTHGATE PKWY
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-3024
Practice Address - Country:US
Practice Address - Phone:740-781-0320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH236Medicaid