Provider Demographics
NPI:1245673771
Name:SIMMONS, BLAKE (MS)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11011 SHERIDAN ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33026-1505
Mailing Address - Country:US
Mailing Address - Phone:954-589-1038
Mailing Address - Fax:866-883-9515
Practice Address - Street 1:11011 SHERIDAN ST
Practice Address - Street 2:SUITE 304
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33026-1505
Practice Address - Country:US
Practice Address - Phone:954-589-1038
Practice Address - Fax:866-883-9515
Is Sole Proprietor?:No
Enumeration Date:2013-04-15
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst