MEDICARE: MELODIE SIMMONS LPC, CEDS-S

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	101YM0800X	Mental Health Counselor	16331	AZ
2	101YP2500X	Professional Counselor	LPC-16331	AZ

General Provider Information

NPI Number	:	1679171094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELODIE SIMMONS LPC, CEDS-S

Provider Business Mailing Address
First Line	:	2309 W LONG SHADOW TRL
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85085-6084
Country	:	US
Telephone Number	:	623-236-8631
Fax Number	:

Provider Business Practice Location Address
First Line	:	2309 W LONG SHADOW TRL
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85085-6084
Country	:	US
Telephone Number	:	623-236-8631
Fax Number	:

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

Provider Enumeration Date	:	10/16/2020
Last Update Date	:	09/13/2021

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