Provider Demographics
NPI:1477591519
Name:SIMMONDS, ROBERT B (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:B
Last Name:SIMMONDS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLDG R-17 CONWAY ST
Mailing Address - Street 2:BHD/TBI CLINIC
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:315-772-2364
Mailing Address - Fax:315-772-8829
Practice Address - Street 1:BLDG R-17 CONWAY ST
Practice Address - Street 2:BHD/TBI CLINIC
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-2364
Practice Address - Fax:315-772-8829
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11553103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP11553Medicare ID - Type Unspecified