Provider Demographics
NPI:1003186826
Name:INGERSOLL, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:INGERSOLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:OK
Mailing Address - Zip Code:73068-8473
Mailing Address - Country:US
Mailing Address - Phone:405-568-2698
Mailing Address - Fax:
Practice Address - Street 1:408 N 6TH ST
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:OK
Practice Address - Zip Code:73068-8473
Practice Address - Country:US
Practice Address - Phone:405-568-2698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor