Provider Demographics
NPI:1205375136
Name:INGRAM, ZILLAH LISE (MED, NCC, LGPC)
Entity Type:Individual
Prefix:MRS
First Name:ZILLAH
Middle Name:LISE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MED, NCC, LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5457 TWIN KNOLLS RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3259
Mailing Address - Country:US
Mailing Address - Phone:410-864-6386
Mailing Address - Fax:410-992-6671
Practice Address - Street 1:5457 TWIN KNOLLS RD
Practice Address - Street 2:SUITE 301
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3259
Practice Address - Country:US
Practice Address - Phone:410-864-6386
Practice Address - Fax:410-992-6671
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-12
Last Update Date:2017-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP7514106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist