Provider Demographics
NPI:1164887170
Name:SUZAN B. SIMMONS, PH.D,,PLLC
Entity Type:Organization
Organization Name:SUZAN B. SIMMONS, PH.D,,PLLC
Other - Org Name:SUZAN B. SIMMONS, PH.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:580-761-3799
Mailing Address - Street 1:PO BOX 1230
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74602-1230
Mailing Address - Country:US
Mailing Address - Phone:580-761-3799
Mailing Address - Fax:
Practice Address - Street 1:1916 LAKE RD
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-4800
Practice Address - Country:US
Practice Address - Phone:580-761-3799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1150103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKA104155OtherMEDICARE INDIVIDUAL PTAN