Provider Demographics
NPI:1871180018
Name:SIMMONS, ENDIA DOMINIQUE (CDCA)
Entity Type:Individual
Prefix:
First Name:ENDIA
Middle Name:DOMINIQUE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 E FAIRGROUND ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-2639
Mailing Address - Country:US
Mailing Address - Phone:740-360-8910
Mailing Address - Fax:
Practice Address - Street 1:1271 CRESCENT HIEGHTS RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302
Practice Address - Country:US
Practice Address - Phone:740-360-8910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.75276101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)