Healthcare Provider Details

I. General information

NPI: 1386209856
Provider Name (Legal Business Name): KA-LISHA MAE SIMONS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 FERN CREEK DR
STATESVILLE NC
28625-9376
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 704-818-9191
  • Fax: 704-872-3782
Mailing address:
  • Phone: 704-874-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number25MA11444800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2024-00805
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: