Healthcare Provider Details

I. General information

NPI: 1942554662
Provider Name (Legal Business Name): AMY NICHELLE SIMMONS MOT, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GATEWAY DR STE 109
IRVING TX
75063-2743
US

IV. Provider business mailing address

1416 BETTE DR
MESQUITE TX
75149-6206
US

V. Phone/Fax

Practice location:
  • Phone: 214-591-0061
  • Fax:
Mailing address:
  • Phone: 325-214-0716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number114116
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: