MEDICARE: MR. WALTER G SIMMONS LCSW

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	1041C0700X	Clinical Social Worker	046310	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A300056850	OTHER	NY	MEDICARE PTAN

General Provider Information

NPI Number	:	1972640647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WALTER G SIMMONS LCSW

Provider Business Mailing Address
First Line	:	325 KING ST
Second Line	:	4C
City	:	PORT CHESTER
State	:	NY
Zip	:	10573-4050
Country	:	US
Telephone Number	:	914-937-9204
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 KING ST
Second Line	:	4C
City	:	PORT CHESTER
State	:	NY
Zip	:	10573-4050
Country	:	US
Telephone Number	:	914-937-9204
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	10/16/2012

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