Provider Demographics
NPI:1457042079
Name:SIMON, KEIANNA (LMHC)
Entity Type:Individual
Prefix:
First Name:KEIANNA
Middle Name:
Last Name:SIMON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 NE WHISTLING DUCK WAY
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3538
Mailing Address - Country:US
Mailing Address - Phone:718-360-7742
Mailing Address - Fax:
Practice Address - Street 1:3800 W BROWARD BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1018
Practice Address - Country:US
Practice Address - Phone:954-587-1008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH22196101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health