Provider Demographics
NPI:1043745557
Name:INGRAM, VICTOR SHAWN (LSW)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:SHAWN
Last Name:INGRAM
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 CALIFORNIA CONDOR AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-4804
Mailing Address - Country:US
Mailing Address - Phone:702-277-6382
Mailing Address - Fax:702-453-3151
Practice Address - Street 1:4109 CALIFORNIA CONDOR AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-4804
Practice Address - Country:US
Practice Address - Phone:702-277-6382
Practice Address - Fax:702-453-3151
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-23
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7464-S1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical