Provider Demographics
NPI:1912062415
Name:SIMON, GEORGE MICHAEL (MS)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:MICHAEL
Last Name:SIMON
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 GRAND HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3128
Mailing Address - Country:US
Mailing Address - Phone:631-786-5542
Mailing Address - Fax:631-667-1708
Practice Address - Street 1:144 LAKE AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-4219
Practice Address - Country:US
Practice Address - Phone:631-786-5542
Practice Address - Fax:631-667-1708
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000176106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist