MEDICARE: SHAUNTA SIMMONS RBT

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	106S00000X	Behavior Technician	21-159042	GA

General Provider Information

NPI Number	:	1700471943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAUNTA SIMMONS RBT

Provider Business Mailing Address
First Line	:	206 SUGARMILL BLVD
Second Line	:
City	:	SAINT MARYS
State	:	GA
Zip	:	31558-4496
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	206 SUGARMILL BLVD
Second Line	:
City	:	SAINT MARYS
State	:	GA
Zip	:	31558-4496
Country	:	US
Telephone Number	:	470-400-3177
Fax Number	:

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

Provider Enumeration Date	:	03/09/2021
Last Update Date	:	01/21/2022

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