Provider Demographics
NPI:1467480343
Name:SIMMONS, SHANNON B (MS, LPC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:B
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 W HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-2144
Mailing Address - Country:US
Mailing Address - Phone:417-549-0943
Mailing Address - Fax:417-667-2281
Practice Address - Street 1:815 S ASH ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3222
Practice Address - Country:US
Practice Address - Phone:417-667-8352
Practice Address - Fax:417-667-9216
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006005029101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490620606Medicaid