Healthcare Provider Details

I. General information

NPI: 1538204177
Provider Name (Legal Business Name): LARRY WAYNE SIMMONS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3204 NASH ST N
WILSON NC
27896-1231
US

IV. Provider business mailing address

PO BOX 8085
WILSON NC
27893-1085
US

V. Phone/Fax

Practice location:
  • Phone: 252-237-1626
  • Fax: 252-237-2488
Mailing address:
  • Phone: 252-237-1626
  • Fax: 252-237-2488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC000013
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6002178
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: