Healthcare Provider Details

I. General information

NPI: 1447135801
Provider Name (Legal Business Name): MIRELLA LIDIA SIMON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2025
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2185 W GRANT LINE RD
TRACY CA
95377-7309
US

IV. Provider business mailing address

8351 PINOT GRIGIO ST
ROSEVILLE CA
95747-6680
US

V. Phone/Fax

Practice location:
  • Phone: 209-839-3200
  • Fax:
Mailing address:
  • Phone: 530-713-2237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: