Healthcare Provider Details

I. General information

NPI: 1871051425
Provider Name (Legal Business Name): PORTIA SIMMONS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2019
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 BAINBRIDGE DR
CHARLESTON SC
29407-4240
US

IV. Provider business mailing address

17 BAINBRIDGE DR
CHARLESTON SC
29407-4240
US

V. Phone/Fax

Practice location:
  • Phone: 843-709-7356
  • Fax:
Mailing address:
  • Phone: 843-709-7356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberCOU.10506
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCOU.10506
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: