Provider Demographics
NPI:1699581892
Name:SIMMONS, DEVON MARSHAL
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:MARSHAL
Last Name:SIMMONS
Suffix:
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 1:2020 ASPEN WAY CT
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0028
Mailing Address - Country:US
Mailing Address - Phone:707-293-5515
Mailing Address - Fax:
Practice Address - Street 1:1001 VAN BUREN AVE
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-5541
Practice Address - Country:US
Practice Address - Phone:704-628-6053
Practice Address - Fax:704-628-6702
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA6999225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant