Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health |
NPI | 1912666926 |
---|---|
Provider Name | Mr. Burnell Marcus Simmons JR. |
First Address | Philadelphia, PA 19141-2710 |
Second Address | Philadelphia, PA 19141-2710 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/12/2021 |
Last Update Date | 17/12/2021 |