Provider Demographics
NPI:1265079636
Name:SIMMONS, COLE CASIMIR (DPT, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:CASIMIR
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:DPT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4426 ETZLER RD
Mailing Address - Street 2:
Mailing Address - City:CASEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48725-9743
Mailing Address - Country:US
Mailing Address - Phone:989-553-0658
Mailing Address - Fax:
Practice Address - Street 1:4426 ETZLER RD
Practice Address - Street 2:
Practice Address - City:CASEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48725-9743
Practice Address - Country:US
Practice Address - Phone:989-553-0658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI5501303269225100000X
MI26010025522255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty