Provider Demographics
NPI:1194552612
Name:CROSS, SIMON TERRY (LCDCI)
Entity type:Individual
Prefix:MR
First Name:SIMON
Middle Name:TERRY
Last Name:CROSS
Suffix:
Gender:M
Credentials:LCDCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 STAGHORN DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-2595
Mailing Address - Country:US
Mailing Address - Phone:432-813-9983
Mailing Address - Fax:
Practice Address - Street 1:200 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-4621
Practice Address - Country:US
Practice Address - Phone:432-618-0028
Practice Address - Fax:432-620-8220
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
TX61202101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)