Provider Demographics
NPI:1184765661
Name:SIMON, STEVEN JACK (PHD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:JACK
Last Name:SIMON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1238 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1714
Mailing Address - Country:US
Mailing Address - Phone:502-587-1131
Mailing Address - Fax:502-228-5183
Practice Address - Street 1:1238 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1714
Practice Address - Country:US
Practice Address - Phone:502-587-1131
Practice Address - Fax:502-228-5183
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY371103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical