Provider Demographics
NPI:1164070975
Name:SIMMONS, AMANDA R
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:SIMMONS
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 1:6505 SHILOH RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-1645
Mailing Address - Country:US
Mailing Address - Phone:678-648-7644
Mailing Address - Fax:678-882-7040
Practice Address - Street 1:3330 CHASTAIN MEADOWS PKWY NW STE 200
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5881
Practice Address - Country:US
Practice Address - Phone:678-648-7644
Practice Address - Fax:678-882-7040
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19-97090106S00000X
GARBT-21-188094106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician