Provider Demographics
NPI:1770225757
Name:SIMMONS, RYAN (LMSW)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 TIPTON DR E
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-3619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58 TIPTON DR E
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-3619
Practice Address - Country:US
Practice Address - Phone:914-882-8967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111375390200000X
NY111375390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program