Basic Information
| Provider Information | |||||||||
| NPI: | 1730416223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMMONS | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | JANE | ||||||||
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| Credential: | MHPP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 OZARK DR | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721164591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016610720 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 ALDERSGATE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016610720 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2009 | ||||||||
| LastUpdateDate: | 11/04/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.