Provider Demographics
NPI:1518662683
Name:INGRAM, CRYSTAL DANIELLE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DANIELLE
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 1:141 S CENTER ST STE 302
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2543
Mailing Address - Country:US
Mailing Address - Phone:307-274-2693
Mailing Address - Fax:
Practice Address - Street 1:141 S CENTER ST STE 302
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2543
Practice Address - Country:US
Practice Address - Phone:307-274-2693
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional