Provider Demographics
NPI:1477846160
Name:INGRAM, MARK J (PSY D)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
Last Name:INGRAM
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28625 S WESTERN AVE # 2024
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-0810
Mailing Address - Country:US
Mailing Address - Phone:424-271-2933
Mailing Address - Fax:
Practice Address - Street 1:22330 HAWTHORNE BLVD
Practice Address - Street 2:STE 207
Practice Address - City:TORRENCE
Practice Address - State:CA
Practice Address - Zip Code:90505
Practice Address - Country:US
Practice Address - Phone:424-271-2933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-27
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY24268103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist