Provider Demographics
NPI:1255442166
Name:SIMON, JOANN (LICAC, RD, LDN)
Entity type:Individual
Prefix:MS
First Name:JOANN
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:LICAC, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 EVERGREEN CIR
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-2531
Mailing Address - Country:US
Mailing Address - Phone:617-470-6205
Mailing Address - Fax:
Practice Address - Street 1:524 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MA
Practice Address - Zip Code:01778-1833
Practice Address - Country:US
Practice Address - Phone:508-358-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0170171100000X
MA1980133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered