Healthcare Provider Details

I. General information

NPI: 1073399671
Provider Name (Legal Business Name): MR. SAMUEL MYRON SIMON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9425 SUNSET DR STE 251
MIAMI FL
33173-5457
US

IV. Provider business mailing address

10671 N KENDALL DR
MIAMI FL
33176-1510
US

V. Phone/Fax

Practice location:
  • Phone: 786-310-6004
  • Fax:
Mailing address:
  • Phone: 786-416-0811
  • Fax: 786-558-5483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW23498
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number1571845
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberNCPS0100179
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: