Provider Demographics
NPI:1336479989
Name:INGRAM, KYLE (OTR)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 NE STEPHENS ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3158
Mailing Address - Country:US
Mailing Address - Phone:541-673-5770
Mailing Address - Fax:541-673-5774
Practice Address - Street 1:470 NE STEPHENS ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3158
Practice Address - Country:US
Practice Address - Phone:541-673-5770
Practice Address - Fax:541-673-5774
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR579225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist