Provider Demographics
NPI:1962747675
Name:SIMMONS, CRYSTAL CHERIE (BA,QMHP,QSAP, LCASA)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:CHERIE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:BA,QMHP,QSAP, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E 6TH ST # 103
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2918
Mailing Address - Country:US
Mailing Address - Phone:704-430-1038
Mailing Address - Fax:
Practice Address - Street 1:100 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1002
Practice Address - Country:US
Practice Address - Phone:704-376-7447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X
NC20101101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)