Provider Demographics
NPI:1811156573
Name:SIMONS, JUSTIN O (PCC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:O
Last Name:SIMONS
Suffix:
Gender:M
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 BURLINGTON OVAL DR
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-1453
Mailing Address - Country:US
Mailing Address - Phone:440-636-3914
Mailing Address - Fax:
Practice Address - Street 1:35000 CHARDON RD
Practice Address - Street 2:# 210
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-9012
Practice Address - Country:US
Practice Address - Phone:440-951-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE 0500992101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional