Healthcare Provider Details

I. General information

NPI: 1588937379
Provider Name (Legal Business Name): IC HOPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E FRANKLIN ST SUITE 717
RICHMOND VA
23219-2322
US

IV. Provider business mailing address

PO BOX 793
MECHANICSVILLE VA
23111-0793
US

V. Phone/Fax

Practice location:
  • Phone: 804-237-9420
  • Fax:
Mailing address:
  • Phone: 804-363-8964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0710102443
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number0710102443
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number0710102443
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number0710102443
License Number StateVA

VIII. Authorized Official

Name: MRS. IDA M NELSON
Title or Position: CO-OWNER
Credential: CSAC
Phone: 804-363-8964