Provider Demographics
NPI:1275080293
Name:INGRAM, MALLORY (MA, LPC, R-DMT)
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MA, LPC, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 N RACINE AVE STE 2160
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-4045
Mailing Address - Country:US
Mailing Address - Phone:312-946-2393
Mailing Address - Fax:
Practice Address - Street 1:1100 S MAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-4229
Practice Address - Country:US
Practice Address - Phone:312-602-1466
Practice Address - Fax:312-733-5211
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.011231101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1407971211Medicaid