=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760258065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMAN HEALING JOURNEY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2023
-----------------------------------------------------
Last Update Date | 11/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 VULCAN RD STE 300
-----------------------------------------------------
City | HOMEWOOD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35209-4701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-931-5056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 DOUG BLVD STE 107
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-931-5056
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ADEZZA DUBOSE-WILLIAMS
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 205-261-8305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------