Provider Demographics
NPI:1760719504
Name:SIMMONS, DIANE OCTAVIA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:OCTAVIA
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 RARITAN AVE STE 420
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08904-2439
Mailing Address - Country:US
Mailing Address - Phone:732-692-7348
Mailing Address - Fax:
Practice Address - Street 1:85 RARITAN AVE STE 420
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:08904-2439
Practice Address - Country:US
Practice Address - Phone:732-692-7348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-16
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00196200101YP2500X
NJ35S100492100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional