Provider Demographics
NPI:1700213246
Name:SIMMONS, EMMA RAE (ATC)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:RAE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1195 NORTH AVE
Mailing Address - Street 2:APT. 404
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05408-2772
Mailing Address - Country:US
Mailing Address - Phone:802-535-9415
Mailing Address - Fax:
Practice Address - Street 1:426 INDUSTRIAL AVE
Practice Address - Street 2:SUITE 190
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-4448
Practice Address - Country:US
Practice Address - Phone:802-860-4360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104.00966702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer