Provider Demographics
NPI:1376916759
Name:MICHELLE INGRAM-SMITH
Entity Type:Organization
Organization Name:MICHELLE INGRAM-SMITH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED INDEPENDENT PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:INGRAM-SMTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-476-2533
Mailing Address - Street 1:6221 MONTICELLO RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-2910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6221 MONTICELLO RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-2910
Practice Address - Country:US
Practice Address - Phone:803-814-1091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10827251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health