Provider Demographics
NPI:1609388578
Name:SIMO FOSSOUO, CORTNEY (BCBA)
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:
Last Name:SIMO FOSSOUO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:CORTNEY
Other - Middle Name:
Other - Last Name:SALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:406 KAMBER LN
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-4539
Mailing Address - Country:US
Mailing Address - Phone:214-454-2447
Mailing Address - Fax:
Practice Address - Street 1:611 S HIGHWAY 78 STE 124
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-4134
Practice Address - Country:US
Practice Address - Phone:972-429-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-31
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-20-45990103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst