Basic Information
| Provider Information | |||||||||
| NPI: | 1184119299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMON | ||||||||
| FirstName: | MARNI | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MA, CCC-SLP, BCS-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 565 ACACIA AVE | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE VILLAGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329042501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508579343 | ||||||||
| FaxNumber: | 8448487557 | ||||||||
| Practice Location | |||||||||
| Address1: | 565 ACACIA AVE | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE VILLAGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508579343 | ||||||||
| FaxNumber: | 8448487557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2018 | ||||||||
| LastUpdateDate: | 03/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA15801 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 222Q00000X | SA15801 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.