Provider Demographics
NPI:1063249456
Name:SIMMONS, ROOSEVELT DOMINIC (DPT)
Entity type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:DOMINIC
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:ROOSEVELT KAI
Other - Middle Name:
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:4509 LINDEN AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-6531
Mailing Address - Country:US
Mailing Address - Phone:951-249-5330
Mailing Address - Fax:
Practice Address - Street 1:4400 STONE WAY N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-7485
Practice Address - Country:US
Practice Address - Phone:206-536-3049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61572474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist