MEDICARE: INDIVIDUALIZED PURSUANCE OF HOPE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1477143592
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIVIDUALIZED PURSUANCE OF HOPE, LLC

Provider Business Mailing Address
First Line	:	1261 STAFFORD DR
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36117-8904
Country	:	US
Telephone Number	:	334-549-8316
Fax Number	:	334-612-7152

Provider Business Practice Location Address
First Line	:	4171 LOMAC ST STE D-2
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36106-2945
Country	:	US
Telephone Number	:	334-549-8316
Fax Number	:

Authorized Official
Title or Position	:	COUNSELOR/OWNER
Name	:	MS. ILENE D HOLCOMBE
Credential	:	LPC
Telephone Number	:	334-549-8316

Provider Enumeration Date	:	01/22/2021
Last Update Date	:	01/22/2021

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