Provider Demographics
NPI:1083446736
Name:ULLISSE, SIMONE
Entity type:Individual
Prefix:MRS
First Name:SIMONE
Middle Name:
Last Name:ULLISSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 CREEKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-6206
Mailing Address - Country:US
Mailing Address - Phone:904-572-6311
Mailing Address - Fax:
Practice Address - Street 1:1821 CREEKVIEW DR
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-6206
Practice Address - Country:US
Practice Address - Phone:904-844-1624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services