=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801509856
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORTIFY CHRISTIAN COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2023
-----------------------------------------------------
Last Update Date | 01/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4958 VALLEYDALE RD STE 250
-----------------------------------------------------
City | HOOVER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242-7723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-677-6067
-----------------------------------------------------
Fax | 205-588-0786
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 PIN OAK DR
-----------------------------------------------------
City | CHELSEA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35043-5213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-677-6067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | MR. JOHN THREADCRAFT
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 205-677-6067
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP1600X
-----------------------------------------------------
Taxonomy Name | Pastoral Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------