Provider Demographics
NPI:1083371611
Name:INGRAM, PHYLLIS (LMHC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3107 SAWGRASS VILLAGE CIR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-5032
Mailing Address - Country:US
Mailing Address - Phone:904-373-0942
Mailing Address - Fax:
Practice Address - Street 1:3107 SAWGRASS VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-5032
Practice Address - Country:US
Practice Address - Phone:904-373-0942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH004028101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty