Provider Demographics
NPI:1023420742
Name:HERON-CARMIGNANI, SIMONE (PHD)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:HERON-CARMIGNANI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 831
Mailing Address - Street 2:
Mailing Address - City:OCCIDENTAL
Mailing Address - State:CA
Mailing Address - Zip Code:95465-0831
Mailing Address - Country:US
Mailing Address - Phone:707-483-7046
Mailing Address - Fax:
Practice Address - Street 1:2710 MIDDLEFIELD RD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3404
Practice Address - Country:US
Practice Address - Phone:707-483-7046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29628103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical