Provider Demographics
NPI:1164287504
Name:SIMMONS, GORDON BLAKE
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:BLAKE
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3531 BRIARCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-1609
Mailing Address - Country:US
Mailing Address - Phone:214-402-4704
Mailing Address - Fax:
Practice Address - Street 1:1101 RAINTREE CIR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4922
Practice Address - Country:US
Practice Address - Phone:214-509-0029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist