Provider Demographics
NPI:1104048925
Name:JONATHAN ALAN SIMONS PHD PC
Entity type:Organization
Organization Name:JONATHAN ALAN SIMONS PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT-OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:CLAIRE
Authorized Official - Last Name:STELLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-828-0502
Mailing Address - Street 1:PO BOX 859
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-0859
Mailing Address - Country:US
Mailing Address - Phone:843-828-0502
Mailing Address - Fax:843-828-4402
Practice Address - Street 1:1506 AZALEA DR
Practice Address - Street 2:STE 602
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-5232
Practice Address - Country:US
Practice Address - Phone:843-828-0502
Practice Address - Fax:843-828-4402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC639103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0245Medicaid
SCQ313770283Medicare ID - Type Unspecified