Provider Demographics
NPI:1447077797
Name:SONG, SIMON
Entity type:Individual
Prefix:MR
First Name:SIMON
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 PELHAM AVE
Mailing Address - Street 2:
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-3430
Mailing Address - Country:US
Mailing Address - Phone:845-323-7565
Mailing Address - Fax:
Practice Address - Street 1:1 PLAZA LN STE 1
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-1829
Practice Address - Country:US
Practice Address - Phone:551-264-9565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37FA00026000106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist