Provider Demographics
NPI:1699144402
Name:WILLIE SIMMONS
Entity type:Organization
Organization Name:WILLIE SIMMONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MR.
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:LICSWC
Authorized Official - Phone:240-432-9338
Mailing Address - Street 1:12500 CLEARWATER WAY
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-6600
Mailing Address - Country:US
Mailing Address - Phone:240-432-9338
Mailing Address - Fax:
Practice Address - Street 1:12500 CLEARWATER WAY
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-6600
Practice Address - Country:US
Practice Address - Phone:240-432-9338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20930251S00000X
DCLC50079182251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health