Healthcare Provider Details

I. General information

NPI: 1134865470
Provider Name (Legal Business Name): GEORGE M. ISHMAN ALC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 ZELDA RD
MONTGOMERY AL
36106-2648
US

IV. Provider business mailing address

3354 DREXEL RD
MONTGOMERY AL
36106-3206
US

V. Phone/Fax

Practice location:
  • Phone: 334-262-7787
  • Fax:
Mailing address:
  • Phone: 334-220-6406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC4124A
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: