Provider Demographics
NPI:1275024028
Name:INGRAM, BROOKE BOUCHER
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:BOUCHER
Last Name:INGRAM
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 1:7 MCKENNA COMMONS CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-2633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1225 S CHURCH ST APT 336
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4186
Practice Address - Country:US
Practice Address - Phone:704-891-6253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-27
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-19-9987106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst