Provider Demographics
NPI:1457480816
Name:SIMMONS, GLEN DALE (MA)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:DALE
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-2162
Mailing Address - Country:US
Mailing Address - Phone:931-455-5269
Mailing Address - Fax:931-455-5269
Practice Address - Street 1:1803 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2201
Practice Address - Country:US
Practice Address - Phone:931-461-1324
Practice Address - Fax:931-461-1304
Is Sole Proprietor?:No
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor