Provider Demographics
NPI:1518590017
Name:INGLISA, MARY JO
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:INGLISA
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 1:2008 E JACKSON ST APT 10
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1842
Mailing Address - Country:US
Mailing Address - Phone:719-217-8127
Mailing Address - Fax:
Practice Address - Street 1:6190 BARNES RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80922-2600
Practice Address - Country:US
Practice Address - Phone:719-247-1511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician