Provider Demographics
NPI:1275302036
Name:DIRTON, INGRAM MALCOLM KERRY
Entity Type:Individual
Prefix:
First Name:INGRAM
Middle Name:MALCOLM KERRY
Last Name:DIRTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 S LINDON LN APT 5020A
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-3221
Mailing Address - Country:US
Mailing Address - Phone:864-979-1325
Mailing Address - Fax:
Practice Address - Street 1:2102 W BETHANY HOME RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1935
Practice Address - Country:US
Practice Address - Phone:602-774-4745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-08076T101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor