Provider Demographics
NPI:1164613733
Name:INGRAM, ASA (CAS)
Entity Type:Individual
Prefix:MR
First Name:ASA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 CHANEY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2722
Mailing Address - Country:US
Mailing Address - Phone:951-674-5354
Mailing Address - Fax:951-674-5227
Practice Address - Street 1:2055 N PERRIS BLVD
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2509
Practice Address - Country:US
Practice Address - Phone:951-674-5354
Practice Address - Fax:951-674-5227
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5542101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor