Provider Demographics
NPI:1922695485
Name:SIMMONS, KENYONA
Entity Type:Individual
Prefix:
First Name:KENYONA
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6609 GREELEY AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-1828
Mailing Address - Country:US
Mailing Address - Phone:937-405-5322
Mailing Address - Fax:
Practice Address - Street 1:6609 GREELEY AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-1828
Practice Address - Country:US
Practice Address - Phone:937-405-5322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTH902036103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily