Provider Demographics
NPI:1609485275
Name:SIMMS, ISRAEL GREGORY
Entity Type:Individual
Prefix:
First Name:ISRAEL
Middle Name:GREGORY
Last Name:SIMMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 E MIRACLE STRIP PKWY STE 503
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1991
Mailing Address - Country:US
Mailing Address - Phone:850-301-0438
Mailing Address - Fax:855-445-0214
Practice Address - Street 1:124 E MIRACLE STRIP PKWY STE 503
Practice Address - Street 2:
Practice Address - City:MARY ESTHER
Practice Address - State:FL
Practice Address - Zip Code:32569-1991
Practice Address - Country:US
Practice Address - Phone:850-301-0438
Practice Address - Fax:855-445-0214
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-128891106S00000X
FL1-24-72216103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst