Provider Demographics
NPI:1225786296
Name:INGRAM, DETRAVEUS (CADC-R)
Entity Type:Individual
Prefix:MR
First Name:DETRAVEUS
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:CADC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 NEEDMORE RD
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NC
Mailing Address - Zip Code:28327-9245
Mailing Address - Country:US
Mailing Address - Phone:910-638-2134
Mailing Address - Fax:
Practice Address - Street 1:20 PAGE DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8847
Practice Address - Country:US
Practice Address - Phone:910-235-9090
Practice Address - Fax:910-235-9093
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCADC-27212101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)