=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821694928
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSAN GORYEB SIMMS, LICENSED CLINICAL SOCIAL WORKER, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2020
-----------------------------------------------------
Last Update Date | 12/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 MAIN ST
-----------------------------------------------------
City | PORT JEFFERSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11777-2278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-946-3495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16 STORYBOOK LN
-----------------------------------------------------
City | EAST SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-1727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-946-3495
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUSAN SIMMS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 516-946-3495
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------