Provider Demographics
NPI:1053073692
Name:INGRAM, CHARLES DEWITT
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DEWITT
Last Name:INGRAM
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 1:5555 N TACOMA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3548
Mailing Address - Country:US
Mailing Address - Phone:317-209-7970
Mailing Address - Fax:
Practice Address - Street 1:5555 N TACOMA AVE STE 2
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3548
Practice Address - Country:US
Practice Address - Phone:317-209-7970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health