Provider Demographics
NPI:1629362819
Name:SIMONSON, CLINTON SCOTT JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:SCOTT
Last Name:SIMONSON
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11003 MONAHAN PARK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78254-5358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:85 NE LOOP 410
Practice Address - Street 2:SUITE 610
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-5829
Practice Address - Country:US
Practice Address - Phone:210-591-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-05
Last Update Date:2011-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2078669225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant