Provider Demographics
NPI:1043462450
Name:FORTUNE, TIVICA (MS, LPC)
Entity Type:Individual
Prefix:
First Name:TIVICA
Middle Name:
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2282
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35201-2282
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 SOUTHLAND DR
Practice Address - Street 2:SUITE 155-H
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35226-3710
Practice Address - Country:US
Practice Address - Phone:205-585-5474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2645101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional