MEDICARE: SUZAN B. SIMMONS, PH.D,,PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	1150	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OKA104155	OTHER	OK	MEDICARE INDIVIDUAL PTAN

General Provider Information

NPI Number	:	1164887170
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUZAN B. SIMMONS, PH.D,,PLLC

Provider Business Mailing Address
First Line	:	PO BOX 1230
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74602-1230
Country	:	US
Telephone Number	:	580-761-3799
Fax Number	:

Provider Business Practice Location Address
First Line	:	1916 LAKE RD
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74604-4800
Country	:	US
Telephone Number	:	580-761-3799
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. SUZAN B SIMMONS
Credential	:	PH.D.
Telephone Number	:	580-761-3799

Provider Enumeration Date	:	12/17/2015
Last Update Date	:	12/17/2015

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