Provider Demographics
NPI:1043820459
Name:SIMEON, STEPHEN (LAC)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:SIMEON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19905 112TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2107
Mailing Address - Country:US
Mailing Address - Phone:929-231-0350
Mailing Address - Fax:
Practice Address - Street 1:2011 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-2733
Practice Address - Country:US
Practice Address - Phone:646-822-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-01
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006202-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006202-1OtherNEW YORK STATE OFFICE OF PROFESSIONAL