MEDICARE: KRISTA SIMMONS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904009627	VA
2	1041C0700X	Clinical Social Worker	6656	TN
3	1041C0700X	Clinical Social Worker	SW15407	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6656	OTHER	TN	LCSW
2	SW15407	OTHER	FL	LCSW
3	0904009627	OTHER	VA	LCSW

General Provider Information

NPI Number	:	1669957791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTA SIMMONS LCSW

Provider Business Mailing Address
First Line	:	1992 LEWIS TURNER BLVD STE 1067
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1255
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1992 LEWIS TURNER BLVD STE 1067
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1255
Country	:	US
Telephone Number	:	540-353-3280
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2018
Last Update Date	:	10/24/2024

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