Provider Demographics
NPI:1902281256
Name:SIMMONS, SAMUEL JR (LADC)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:SIMMONS
Suffix:JR
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3442 25TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2504
Mailing Address - Country:US
Mailing Address - Phone:612-721-0106
Mailing Address - Fax:
Practice Address - Street 1:3442 25TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2504
Practice Address - Country:US
Practice Address - Phone:612-721-0106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300322101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN300322OtherLADC