Provider Demographics
NPI:1023214863
Name:INTEGRATED COUNSELING PRACTICE
Entity Type:Organization
Organization Name:INTEGRATED COUNSELING PRACTICE
Other - Org Name:INGRAM COUNSELING PRACTICE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:712-255-0232
Mailing Address - Street 1:1221 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1418
Mailing Address - Country:US
Mailing Address - Phone:712-255-0232
Mailing Address - Fax:712-255-0354
Practice Address - Street 1:1221 PIERCE ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1418
Practice Address - Country:US
Practice Address - Phone:712-255-0232
Practice Address - Fax:712-255-0354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1284251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0791665Medicaid
IA29-97-059OtherRTSS CONTRACT NUMBER