Healthcare Provider Details

I. General information

NPI: 1558967927
Provider Name (Legal Business Name): SYRITA SIMMONS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11901 TOEPPERWEIN RD STE 1106
LIVE OAK TX
78233-3159
US

IV. Provider business mailing address

6111 ROYAL PT
SAN ANTONIO TX
78239-1540
US

V. Phone/Fax

Practice location:
  • Phone: 210-286-9339
  • Fax:
Mailing address:
  • Phone: 210-897-1237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number62479
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: