Provider Demographics
NPI:1326379827
Name:SIMMONS, LEE DAVID JR (MSSW/LISW)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:DAVID
Last Name:SIMMONS
Suffix:JR
Gender:M
Credentials:MSSW/LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 620
Mailing Address - Street 2:
Mailing Address - City:MESCALERO
Mailing Address - State:NM
Mailing Address - Zip Code:88340-0620
Mailing Address - Country:US
Mailing Address - Phone:575-937-4743
Mailing Address - Fax:575-464-4847
Practice Address - Street 1:11 ELM ST
Practice Address - Street 2:
Practice Address - City:MESCALERO
Practice Address - State:NM
Practice Address - Zip Code:88340-0620
Practice Address - Country:US
Practice Address - Phone:575-937-4743
Practice Address - Fax:575-464-4847
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-068611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical