Provider Demographics
NPI:1235351925
Name:SIMMS, KENROY LESLIE (PT)
Entity Type:Individual
Prefix:
First Name:KENROY
Middle Name:LESLIE
Last Name:SIMMS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4349 BAYCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-1811
Mailing Address - Country:US
Mailing Address - Phone:718-541-0128
Mailing Address - Fax:
Practice Address - Street 1:4349 BAYCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1811
Practice Address - Country:US
Practice Address - Phone:718-541-0128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006206-1174400000X
NY036852225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006206-1OtherPTA LICENSE
NY036852OtherPT LICENSE