Provider Demographics
NPI:1487822953
Name:INGRAM, CRYSTAL M
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:M
Last Name:INGRAM
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 1:250 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30601-2244
Mailing Address - Country:US
Mailing Address - Phone:706-542-9700
Mailing Address - Fax:706-227-7249
Practice Address - Street 1:62 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ELBERTON
Practice Address - State:GA
Practice Address - Zip Code:30635-1806
Practice Address - Country:US
Practice Address - Phone:706-213-2048
Practice Address - Fax:706-213-2026
Is Sole Proprietor?:No
Enumeration Date:2008-02-18
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor