Provider Demographics
NPI:1003030388
Name:THOMAS-INGRAM, ANDREA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:THOMAS-INGRAM
Suffix:
Gender:M
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 HILLRIDGE CV
Mailing Address - Street 2:
Mailing Address - City:LIZELLA
Mailing Address - State:GA
Mailing Address - Zip Code:31052-3633
Mailing Address - Country:US
Mailing Address - Phone:478-935-9433
Mailing Address - Fax:478-935-9651
Practice Address - Street 1:348 HILLRIDGE CV
Practice Address - Street 2:
Practice Address - City:LIZELLA
Practice Address - State:GA
Practice Address - Zip Code:31052-3633
Practice Address - Country:US
Practice Address - Phone:478-935-9433
Practice Address - Fax:478-935-9651
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003357235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
366116OtherWELLCARE
115111OtherPEACH STATE HEALTH PLAN