Provider Demographics
NPI:1154857829
Name:SIMMS, MADISON I
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:SIMMS
Suffix:I
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 1:4605 CALVERT RD
Mailing Address - Street 2:APT 201
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-3421
Mailing Address - Country:US
Mailing Address - Phone:443-789-4831
Mailing Address - Fax:
Practice Address - Street 1:1651 OLD MEADOW RD
Practice Address - Street 2:SUITE 600
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-4311
Practice Address - Country:US
Practice Address - Phone:800-828-5659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRBT-16-22205106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician