Provider Demographics
NPI:1295208353
Name:SIMMONS, ERIC BENJAMIN (LMSW)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:BENJAMIN
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5218 39TH AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-3386
Mailing Address - Country:US
Mailing Address - Phone:816-590-6161
Mailing Address - Fax:
Practice Address - Street 1:2701 QUEENS PLZ N
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4020
Practice Address - Country:US
Practice Address - Phone:212-267-2670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101844101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor