Provider Demographics
NPI:1194141796
Name:SIMMONDS, TINITA
Entity type:Individual
Prefix:
First Name:TINITA
Middle Name:
Last Name:SIMMONDS
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:PO BOX 165
Mailing Address - Street 2:
Mailing Address - City:REDAN
Mailing Address - State:GA
Mailing Address - Zip Code:30074-0165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5405 MEMORIAL DR
Practice Address - Street 2:BLDG C
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3234
Practice Address - Country:US
Practice Address - Phone:678-999-2611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-07
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007601101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional