Provider Demographics
NPI:1912238627
Name:GRIFFIN, VON-QUALIS SIMMONS
Entity Type:Individual
Prefix:
First Name:VON-QUALIS
Middle Name:SIMMONS
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 CANARY ISLAND CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-9201
Mailing Address - Country:US
Mailing Address - Phone:407-790-0949
Mailing Address - Fax:
Practice Address - Street 1:520 CANARY ISLAND CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9201
Practice Address - Country:US
Practice Address - Phone:407-790-0949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00000000Medicaid