Provider Demographics
NPI:1619334133
Name:INGRAM, DOROTHY
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
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 1:61 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:TERRYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06786-5413
Mailing Address - Country:US
Mailing Address - Phone:860-202-7828
Mailing Address - Fax:
Practice Address - Street 1:1001 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-3990
Practice Address - Country:US
Practice Address - Phone:860-582-8024
Practice Address - Fax:860-585-0609
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004073225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist