Provider Demographics
NPI:1407460835
Name:SIMMONS, KIM (LMFT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:LMFT
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 9973
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-1973
Mailing Address - Country:US
Mailing Address - Phone:949-929-1177
Mailing Address - Fax:
Practice Address - Street 1:17621 IRVINE BLVD STE 214
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3131
Practice Address - Country:US
Practice Address - Phone:949-929-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA120766106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0OtherNONE