Provider Demographics
NPI:1538204177
Name:SIMMONS, LARRY WAYNE (LCSW)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WAYNE
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8085
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-1085
Mailing Address - Country:US
Mailing Address - Phone:252-237-1626
Mailing Address - Fax:252-237-2488
Practice Address - Street 1:3204 NASH ST N
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-1231
Practice Address - Country:US
Practice Address - Phone:252-237-1626
Practice Address - Fax:252-237-2488
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0000131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002178Medicaid
NC2867003Medicare ID - Type Unspecified