Provider Demographics
NPI:1417068032
Name:SIMMONS, BRIAN K (LISW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1334 NIPA BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-8987
Mailing Address - Country:US
Mailing Address - Phone:641-919-4004
Mailing Address - Fax:319-694-4004
Practice Address - Street 1:1334 NIPA BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-8987
Practice Address - Country:US
Practice Address - Phone:641-919-4004
Practice Address - Fax:319-694-4004
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06571104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI17501Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER