Provider Demographics
NPI:1417157512
Name:INGRAM, STEPHANIE ELIZABETH (PTA)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:INGRAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6903 BORDER BROOK
Mailing Address - Street 2:APT. 802
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238
Mailing Address - Country:US
Mailing Address - Phone:210-542-2922
Mailing Address - Fax:
Practice Address - Street 1:15600 SAN PEDRO AVE
Practice Address - Street 2:STE. 307
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-3740
Practice Address - Country:US
Practice Address - Phone:210-494-2343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2047926171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor