Provider Demographics
NPI:1609142702
Name:SIMONSON, MARY MARSHALL (LPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARSHALL
Last Name:SIMONSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 HERITAGE VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-8492
Mailing Address - Country:US
Mailing Address - Phone:910-619-4650
Mailing Address - Fax:
Practice Address - Street 1:3125 POPLARWOOD CT
Practice Address - Street 2:SUITE 203
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1084
Practice Address - Country:US
Practice Address - Phone:919-571-2932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA8492101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5917231Medicaid
NC5917231Medicaid