Provider Demographics
NPI:1043600828
Name:GRIMES, PORTIA (LPC)
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:GRIMES
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 OLD PEACHTREE RD APT 430
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-2285
Mailing Address - Country:US
Mailing Address - Phone:470-893-3593
Mailing Address - Fax:678-691-4366
Practice Address - Street 1:2995 OLD PEACHTREE RD APT 430
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-2285
Practice Address - Country:US
Practice Address - Phone:470-893-3593
Practice Address - Fax:678-691-4366
Is Sole Proprietor?:No
Enumeration Date:2015-01-30
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013318101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional