Provider Demographics
NPI:1740763192
Name:SIMMONS, MATTHEW JAMES (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 W LINCOLN TRAIL BLVD
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-2047
Mailing Address - Country:US
Mailing Address - Phone:270-352-1061
Mailing Address - Fax:
Practice Address - Street 1:490 W LINCOLN TRAIL BLVD
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-2047
Practice Address - Country:US
Practice Address - Phone:270-352-1061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP2018123225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist