Healthcare Provider Details

I. General information

NPI: 1477839546
Provider Name (Legal Business Name): MR. STEPHEN ALEXANDER SIMMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WING ST
ELGIN IL
60123-2800
US

IV. Provider business mailing address

331 GREENWOOD ACRES DR
DEKALB IL
60115-1031
US

V. Phone/Fax

Practice location:
  • Phone: 847-717-6455
  • Fax: 847-888-0249
Mailing address:
  • Phone: 815-748-5175
  • Fax: 815-748-5175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.005563
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: