Provider Demographics
NPI:1730735630
Name:SIMMONS, BREONNA NICOLE (CCC)
Entity type:Individual
Prefix:
First Name:BREONNA
Middle Name:NICOLE
Last Name:SIMMONS
Suffix:
Gender:F
Credentials:CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 RASPBERRY WAY
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-2659
Mailing Address - Country:US
Mailing Address - Phone:513-706-5541
Mailing Address - Fax:
Practice Address - Street 1:1514 CLEVELAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6977
Practice Address - Country:US
Practice Address - Phone:678-322-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010524235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist