=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477143592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIVIDUALIZED PURSUANCE OF HOPE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2021
-----------------------------------------------------
Last Update Date | 01/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4171 LOMAC ST STE D-2
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36106-2945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-549-8316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1261 STAFFORD DR
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36117-8904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-549-8316
-----------------------------------------------------
Fax | 334-612-7152
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR/OWNER
-----------------------------------------------------
Name | MS. ILENE D HOLCOMBE
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 334-549-8316
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------