Provider Demographics
NPI:1669850376
Name:SIMMONS, MARK DANIEL (LCPC/C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:LCPC/C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WHITTEN HILL RD
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04046-5117
Mailing Address - Country:US
Mailing Address - Phone:207-205-3708
Mailing Address - Fax:
Practice Address - Street 1:103 WHITTEN HILL RD
Practice Address - Street 2:
Practice Address - City:KENNEBUNKPORT
Practice Address - State:ME
Practice Address - Zip Code:04046-5117
Practice Address - Country:US
Practice Address - Phone:207-205-3708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL4378101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health