Provider Demographics
NPI:1003966474
Name:INGRAM, TIMOTHY LEON (MED)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LEON
Last Name:INGRAM
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:113 PINE ST
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-6050
Mailing Address - Country:US
Mailing Address - Phone:904-249-5439
Mailing Address - Fax:904-482-4106
Practice Address - Street 1:9951 ATLANTIC BLVD
Practice Address - Street 2:STE 170
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6584
Practice Address - Country:US
Practice Address - Phone:904-482-4105
Practice Address - Fax:904-482-4106
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH1575101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health