Provider Demographics
NPI:1285415554
Name:SIMMS, DEVEON IVORY SR
Entity type:Individual
Prefix:MR
First Name:DEVEON
Middle Name:IVORY
Last Name:SIMMS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-4613
Mailing Address - Country:US
Mailing Address - Phone:937-838-8645
Mailing Address - Fax:
Practice Address - Street 1:1315 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-4613
Practice Address - Country:US
Practice Address - Phone:937-838-8645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.004389175T00000X
OH187207101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist