Provider Demographics
NPI:1225416886
Name:SIMMONS, MATT (LMT, LR)
Entity Type:Individual
Prefix:MR
First Name:MATT
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:LMT, LR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 56TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6386
Mailing Address - Country:US
Mailing Address - Phone:701-520-3154
Mailing Address - Fax:
Practice Address - Street 1:4955 17TH AVE S STE 116
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3372
Practice Address - Country:US
Practice Address - Phone:701-893-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1361225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist