Provider Demographics
NPI:1619614732
Name:SIMMONS, KEITH THOMAS
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:THOMAS
Last Name:SIMMONS
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:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:GARDEN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95633-0871
Mailing Address - Country:US
Mailing Address - Phone:530-304-1599
Mailing Address - Fax:
Practice Address - Street 1:5607 MOUNT MURPHY ROAD
Practice Address - Street 2:
Practice Address - City:GARDEN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95633-9563
Practice Address - Country:US
Practice Address - Phone:530-333-9460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI41460124101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)