Provider Demographics
NPI:1841507076
Name:SIMONTON, ANGIE M
Entity type:Individual
Prefix:MS
First Name:ANGIE
Middle Name:M
Last Name:SIMONTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGIE
Other - Middle Name:M
Other - Last Name:MASSICOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:700 MARINERS PLAZA DR STE 704A
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-4799
Mailing Address - Country:US
Mailing Address - Phone:985-317-4319
Mailing Address - Fax:855-203-0527
Practice Address - Street 1:5001 HIGHWAY 190 EAST SERVICE RD STE D4-5
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433
Practice Address - Country:US
Practice Address - Phone:985-317-4319
Practice Address - Fax:855-203-0537
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-09
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA75551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2421875Medicaid