Provider Demographics
NPI:1508072075
Name:INGRAM, DESIREE CASSANDRA (MS)
Entity Type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:CASSANDRA
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W 7TH AVE
Mailing Address - Street 2:SUITE 224
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4064
Mailing Address - Country:US
Mailing Address - Phone:405-743-0344
Mailing Address - Fax:
Practice Address - Street 1:116 W 7TH AVE
Practice Address - Street 2:SUITE 224
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4064
Practice Address - Country:US
Practice Address - Phone:405-743-0344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK738106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist