Provider Demographics
NPI:1730325838
Name:SIMMONS, LYDA MONELL (PHD,LPC)
Entity type:Individual
Prefix:DR
First Name:LYDA
Middle Name:MONELL
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:PHD,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 JAMESON DR
Mailing Address - Street 2:
Mailing Address - City:ROEBUCK
Mailing Address - State:SC
Mailing Address - Zip Code:29376-3527
Mailing Address - Country:US
Mailing Address - Phone:864-587-4877
Mailing Address - Fax:864-587-4877
Practice Address - Street 1:110 JAMESON DR
Practice Address - Street 2:
Practice Address - City:ROEBUCK
Practice Address - State:SC
Practice Address - Zip Code:29376-3527
Practice Address - Country:US
Practice Address - Phone:864-587-4877
Practice Address - Fax:864-587-4877
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-20
Last Update Date:2008-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13390101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXLP0021006Medicaid
429691OtherMHN