Provider Demographics
NPI:1275937476
Name:SIMON, CAROL MARIE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:MARIE
Last Name:SIMON
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 1:24535 TOWN CENTER DR APT 6304
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-0802
Mailing Address - Country:US
Mailing Address - Phone:818-326-7302
Mailing Address - Fax:
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-846-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-16
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1109221736101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)