Provider Demographics
NPI:1508307968
Name:SIMMONS, KHADIJAH KASHAY (MSW, CSW)
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:KASHAY
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:MSW, CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W CORNERVIEW ST
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-2742
Mailing Address - Country:US
Mailing Address - Phone:225-647-4105
Mailing Address - Fax:866-234-8190
Practice Address - Street 1:630 W CORNERVIEW ST
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2742
Practice Address - Country:US
Practice Address - Phone:225-647-4105
Practice Address - Fax:866-234-8190
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16088171M00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator