Provider Demographics
NPI:1902586449
Name:SIMONE, MIA ILEENE
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:ILEENE
Last Name:SIMONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W TORRANCE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3600
Mailing Address - Country:US
Mailing Address - Phone:310-374-3300
Mailing Address - Fax:310-374-3307
Practice Address - Street 1:119 W TORRANCE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3600
Practice Address - Country:US
Practice Address - Phone:310-374-3300
Practice Address - Fax:310-374-3307
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician