Provider Demographics
NPI:1447313846
Name:SIMMONS, NATHAN KYLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:KYLE
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 609001
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92160-9001
Mailing Address - Country:US
Mailing Address - Phone:619-528-4600
Mailing Address - Fax:619-528-4600
Practice Address - Street 1:277 RANCHEROS DR
Practice Address - Street 2:SUITE 301
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2976
Practice Address - Country:US
Practice Address - Phone:619-528-4600
Practice Address - Fax:619-528-4625
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25856103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW416OtherPCSD MEDICARE #