Provider Demographics
NPI:1659486918
Name:FITZ-SIMMONS, BRENDA JUNE (LMSW, CADC1, SAP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JUNE
Last Name:FITZ-SIMMONS
Suffix:
Gender:F
Credentials:LMSW, CADC1, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 N THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-1801
Mailing Address - Country:US
Mailing Address - Phone:620-672-3812
Mailing Address - Fax:
Practice Address - Street 1:909 S 2ND ST
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:KS
Practice Address - Zip Code:66434-2774
Practice Address - Country:US
Practice Address - Phone:785-742-7113
Practice Address - Fax:785-742-3085
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSCADC1101YA0400X
KSSAP101YA0400X
KS4166 LMSW104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200434090AMedicaid