Provider Demographics
NPI:1417235425
Name:INGRAM, MARK ANTHONY (LADC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:INGRAM
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7537 S BRADEN AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8202
Mailing Address - Country:US
Mailing Address - Phone:918-857-0269
Mailing Address - Fax:
Practice Address - Street 1:7537 S BRADEN AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8202
Practice Address - Country:US
Practice Address - Phone:918-857-0269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK635101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)