Healthcare Provider Details

I. General information

NPI: 1255750709
Provider Name (Legal Business Name): TAKILA SIMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 04/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 E 3RD ST
FLINT MI
48502-1728
US

IV. Provider business mailing address

3309 SUNSET DR
FLINT MI
48503-2363
US

V. Phone/Fax

Practice location:
  • Phone: 810-233-4031
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number68801091465
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: