Provider Demographics
NPI:1447757984
Name:INGRAM, ERICA SUZANNE (LMT)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:SUZANNE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 SHILOH RD APT 1
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-2628
Mailing Address - Country:US
Mailing Address - Phone:903-312-4644
Mailing Address - Fax:
Practice Address - Street 1:4055 HOGAN DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75709-6930
Practice Address - Country:US
Practice Address - Phone:903-526-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT125649225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist