Provider Demographics
NPI:1740499920
Name:SIMONS, C. J (PHD)
Entity type:Individual
Prefix:DR
First Name:C.
Middle Name:J
Last Name:SIMONS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 DOCK ST # A
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-4628
Mailing Address - Country:US
Mailing Address - Phone:910-343-0813
Mailing Address - Fax:
Practice Address - Street 1:510 DOCK ST APT A
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4688
Practice Address - Country:US
Practice Address - Phone:910-262-1434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6533101YP2500X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist