Provider Demographics
NPI:1588159586
Name:SIMON, STEPHEN G (LMT)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:G
Last Name:SIMON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:866 BURRITT RD
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-9725
Mailing Address - Country:US
Mailing Address - Phone:239-289-1048
Mailing Address - Fax:
Practice Address - Street 1:866 BURRITT RD
Practice Address - Street 2:
Practice Address - City:HILTON
Practice Address - State:NY
Practice Address - Zip Code:14468-9725
Practice Address - Country:US
Practice Address - Phone:239-289-1048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA32663225700000X
NY014116-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist