Provider Demographics
NPI:1407599574
Name:VANDAGRIFF, SIMON
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:VANDAGRIFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 FAIRGROUND RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1283
Mailing Address - Country:US
Mailing Address - Phone:256-712-2822
Mailing Address - Fax:
Practice Address - Street 1:115 FAIRGROUND RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1283
Practice Address - Country:US
Practice Address - Phone:256-712-2822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC4023A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor