MEDICARE: KENYONA SIMMONS

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	103TF0000X	Family Psychologist	TH902036	OH

General Provider Information

NPI Number	:	1922695485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENYONA SIMMONS

Provider Business Mailing Address
First Line	:	6609 GREELEY AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45424-1828
Country	:	US
Telephone Number	:	937-405-5322
Fax Number	:

Provider Business Practice Location Address
First Line	:	6609 GREELEY AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45424-1828
Country	:	US
Telephone Number	:	937-405-5322
Fax Number	:

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

Provider Enumeration Date	:	12/30/2020
Last Update Date	:	12/30/2020

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Directions to “ KENYONA SIMMONS ” Practice Location

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