Provider Demographics
NPI:1114694841
Name:INGHAM, KATRINA M
Entity Type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:M
Last Name:INGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12668 STONE CANYON RD
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2011
Mailing Address - Country:US
Mailing Address - Phone:858-335-5404
Mailing Address - Fax:
Practice Address - Street 1:12668 STONE CANYON RD
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2011
Practice Address - Country:US
Practice Address - Phone:858-335-5404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-47531106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician