Provider Demographics
NPI:1407943780
Name:SIMMONS, SALLY DIANE (MACCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:DIANE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:MACCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8650 FRIENDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:OH
Mailing Address - Zip Code:44254-9708
Mailing Address - Country:US
Mailing Address - Phone:330-948-2046
Mailing Address - Fax:
Practice Address - Street 1:1046 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1102
Practice Address - Country:US
Practice Address - Phone:216-749-6650
Practice Address - Fax:216-749-1655
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-3446235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist