Provider Demographics
NPI:1376230466
Name:INGRAM, COREY DEANGELO
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:DEANGELO
Last Name:INGRAM
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 1:1980 TATNALL SQ APT 302
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32966-8118
Mailing Address - Country:US
Mailing Address - Phone:772-559-3002
Mailing Address - Fax:
Practice Address - Street 1:1980 TATNALL SQ APT 302
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32966-8118
Practice Address - Country:US
Practice Address - Phone:772-559-3002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician