Provider Demographics
NPI:1790053098
Name:SIMMONS, MARVIN LEE III
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:LEE
Last Name:SIMMONS
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1326 PHOENIX DR APT 8
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-5393
Mailing Address - Country:US
Mailing Address - Phone:707-416-3127
Mailing Address - Fax:
Practice Address - Street 1:4505 TAFT AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-3449
Practice Address - Country:US
Practice Address - Phone:510-234-1299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor