Provider Demographics
NPI:1235171224
Name:INGRAM, STACEY LEA (LPC, LSATP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEA
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LPC, LSATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:BRACEY
Mailing Address - State:VA
Mailing Address - Zip Code:23919-1956
Mailing Address - Country:US
Mailing Address - Phone:434-636-5318
Mailing Address - Fax:
Practice Address - Street 1:215 W ATLANTIC ST
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-1223
Practice Address - Country:US
Practice Address - Phone:434-634-5181
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000154101YA0400X
VA0701003316101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional