Provider Demographics
NPI:1063220762
Name:SIMMONS, MITCHEL JD (PTA)
Entity type:Individual
Prefix:
First Name:MITCHEL
Middle Name:JD
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 VZCR 3617
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:75117-4042
Mailing Address - Country:US
Mailing Address - Phone:903-330-1039
Mailing Address - Fax:
Practice Address - Street 1:2055 W GRANDE BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-0526
Practice Address - Country:US
Practice Address - Phone:903-534-0449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-26
Last Update Date:2024-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2185065225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant