Provider Demographics
NPI:1407281769
Name:INGALLS, AMANDA ANN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ANN
Last Name:INGALLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2721 HAVENWOOD COURT
Mailing Address - Street 2:
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045
Mailing Address - Country:US
Mailing Address - Phone:972-571-2121
Mailing Address - Fax:
Practice Address - Street 1:3030 NW EXPRESSWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-5474
Practice Address - Country:US
Practice Address - Phone:405-543-2603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional