Provider Demographics
NPI:1578803896
Name:SIMONS, SAMUEL Z (DPT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:Z
Last Name:SIMONS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-6125
Mailing Address - Country:US
Mailing Address - Phone:920-458-4010
Mailing Address - Fax:920-459-1137
Practice Address - Street 1:1813 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-6125
Practice Address - Country:US
Practice Address - Phone:920-458-4010
Practice Address - Fax:920-459-1137
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11756-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100084443Medicaid