Provider Demographics
NPI:1134884901
Name:SIMMONS, SHARITA MARIE (BA)
Entity type:Individual
Prefix:
First Name:SHARITA
Middle Name:MARIE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 NINA CT
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23602-6530
Mailing Address - Country:US
Mailing Address - Phone:216-306-9721
Mailing Address - Fax:
Practice Address - Street 1:208 NINA CT
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-6530
Practice Address - Country:US
Practice Address - Phone:216-306-9721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAB61735733106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH104862489299Medicaid