Provider Demographics
NPI:1588836555
Name:INGRAM, TERESA (MS;ATC;LAT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MS;ATC;LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 W 2880 S
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6480
Mailing Address - Country:US
Mailing Address - Phone:435-750-0349
Mailing Address - Fax:
Practice Address - Street 1:1450 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:UT
Practice Address - Zip Code:84312-9797
Practice Address - Country:US
Practice Address - Phone:435-257-2500
Practice Address - Fax:435-257-3899
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-30
Last Update Date:2008-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6315811-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer