Provider Demographics
NPI:1669511853
Name:SIMMERMAN, GREGORY ALAN (CCC AUDIOLOGIST)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALAN
Last Name:SIMMERMAN
Suffix:
Gender:
Credentials:CCC AUDIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0719
Mailing Address - Country:US
Mailing Address - Phone:509-837-1617
Mailing Address - Fax:
Practice Address - Street 1:1017 TACOMA AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2291
Practice Address - Country:US
Practice Address - Phone:509-837-1720
Practice Address - Fax:304-344-4641
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVA0062231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9704045000Medicaid
SI9328751Medicare ID - Type Unspecified
WV9704045000Medicaid