Provider Demographics
NPI:1861016255
Name:SIMS, PHILLIP E (CDCA)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:E
Last Name:SIMS
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7955 COUNTY ROAD 107 APT 2
Mailing Address - Street 2:
Mailing Address - City:PROCTORVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45669-8075
Mailing Address - Country:US
Mailing Address - Phone:304-710-0944
Mailing Address - Fax:
Practice Address - Street 1:517 3RD AVE
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:OH
Practice Address - Zip Code:45619-1036
Practice Address - Country:US
Practice Address - Phone:740-451-1455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYCDCA.178180101YA0400X
OHCDCA.173793171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0405300Medicaid