=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811055700
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISS ANJULI IVETTE SIMON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2006
-----------------------------------------------------
Last Update Date | 02/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 335 E MONROE AVE
-----------------------------------------------------
City | BARRON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54812-1479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-537-6174
-----------------------------------------------------
Fax | 715-537-6848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1613 11 1/2 ST
-----------------------------------------------------
City | BARRON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54812-9022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-553-0328
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 15442-132
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 3692125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------