Healthcare Provider Details

I. General information

NPI: 1982306940
Provider Name (Legal Business Name): IZANDRA PATRICE RUDOLPH-HEARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2023
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 ZELDA RD
MONTGOMERY AL
36106-2648
US

IV. Provider business mailing address

2911 ZELDA RD
MONTGOMERY AL
36106-2648
US

V. Phone/Fax

Practice location:
  • Phone: 334-262-7787
  • Fax: 334-262-7795
Mailing address:
  • Phone: 334-262-7787
  • Fax: 334-262-7795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4419
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: