Provider Demographics
NPI:1609131218
Name:SIMMONS, BRENT R (DPT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:R
Last Name:SIMMONS
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 1:2454 W CLAY ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2548
Mailing Address - Country:US
Mailing Address - Phone:636-916-4625
Mailing Address - Fax:636-916-4628
Practice Address - Street 1:605 E BOONESLICK RD
Practice Address - Street 2:SUITE 3
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-2127
Practice Address - Country:US
Practice Address - Phone:636-456-6350
Practice Address - Fax:636-456-6084
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013028735225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO991643009Medicare PIN
MO140380024Medicare PIN