Provider Demographics
NPI:1649872656
Name:SIMS, TINA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:SIMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9203 GRATIS JACKSONBURG RD
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45064-9335
Mailing Address - Country:US
Mailing Address - Phone:937-336-8416
Mailing Address - Fax:
Practice Address - Street 1:9203 GRATIS JACKSONBURG RD
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45064-9335
Practice Address - Country:US
Practice Address - Phone:937-336-8416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
385HR2060X
OHM6800288385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2715959Medicaid