Provider Demographics
NPI:1578807319
Name:INGRAM, TINA RANE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:RANE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:RANE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3172 N RAINBOW BLVD # 5077
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-4534
Mailing Address - Country:US
Mailing Address - Phone:702-472-3791
Mailing Address - Fax:
Practice Address - Street 1:824 WEAVER DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2555
Practice Address - Country:US
Practice Address - Phone:702-472-3791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-17
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory ManagementGroup - Multi-Specialty
No251E00000XAgenciesHome Health