Provider Demographics
NPI:1477670313
Name:SIMMONS, KRISTIN CANDLAND (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:CANDLAND
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1558 E HALE ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-3820
Mailing Address - Country:US
Mailing Address - Phone:480-254-9930
Mailing Address - Fax:
Practice Address - Street 1:1558 E HALE ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-3820
Practice Address - Country:US
Practice Address - Phone:480-254-9930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP2086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ742032Medicaid