Provider Demographics
NPI:1942421003
Name:SIMMONS, GREGORY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:SIMMONS
Suffix:
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 1:201 W MAIN ST STE 4B
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-2734
Mailing Address - Country:US
Mailing Address - Phone:541-414-1720
Mailing Address - Fax:541-414-1721
Practice Address - Street 1:201 W MAIN ST STE 4B
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-2734
Practice Address - Country:US
Practice Address - Phone:541-414-1720
Practice Address - Fax:541-414-1721
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0150Medicaid