Provider Demographics
NPI:1609408863
Name:SIMMONS, MICKEL A
Entity Type:Individual
Prefix:MS
First Name:MICKEL
Middle Name:A
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 CORONA AVE APT A
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45419-2204
Mailing Address - Country:US
Mailing Address - Phone:937-789-9814
Mailing Address - Fax:
Practice Address - Street 1:3425 N BEND RD STE F
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45239-7660
Practice Address - Country:US
Practice Address - Phone:513-389-1087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator