Provider Demographics
NPI:1821113366
Name:SIMMONS, LAURA RAE (MA,LPC)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:RAE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:MA,LPC
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:RAE
Other - Last Name:SIMMONS-FONNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7969 ASHTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2885
Mailing Address - Country:US
Mailing Address - Phone:703-792-7800
Mailing Address - Fax:703-792-5699
Practice Address - Street 1:7969 ASHTON AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2885
Practice Address - Country:US
Practice Address - Phone:703-792-7800
Practice Address - Fax:703-792-5699
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003597101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4945247Medicaid
VA105700OtherBLUE CROSS BLUE SHIELD
VA292848OtherAMERIGROUP