Provider Demographics
NPI:1487752119
Name:SIMON, LARRY MARK (MHC)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:MARK
Last Name:SIMON
Suffix:
Gender:M
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 CUMBERLAND ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-3323
Mailing Address - Country:US
Mailing Address - Phone:401-356-1940
Mailing Address - Fax:401-356-1949
Practice Address - Street 1:68 CUMBERLAND ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-3323
Practice Address - Country:US
Practice Address - Phone:401-356-1940
Practice Address - Fax:401-356-1949
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMHC00146101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI233219OtherBLUE CROSS BLUE SHIELD
RI6267131OtherUNITED HEALTH CARE
RILS40876Medicaid
RI408993OtherBLUE CHIP
RI470076OtherTUFTS