Provider Demographics
NPI:1184119299
Name:SIMON, MARNI B (MA, CCC-SLP, BCS-S)
Entity type:Individual
Prefix:
First Name:MARNI
Middle Name:B
Last Name:SIMON
Suffix:
Gender:F
Credentials:MA, CCC-SLP, BCS-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 ACACIA AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE VILLAGE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-2501
Mailing Address - Country:US
Mailing Address - Phone:850-857-9343
Mailing Address - Fax:844-848-7557
Practice Address - Street 1:565 ACACIA AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE VILLAGE
Practice Address - State:FL
Practice Address - Zip Code:32904
Practice Address - Country:US
Practice Address - Phone:850-857-9343
Practice Address - Fax:844-848-7557
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-30
Last Update Date:2019-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15801235Z00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist