Provider Demographics
NPI:1629649512
Name:INGRAM, MAURICE (PSYD, NCSP)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:PSYD, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S BROAD ST APT 305
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08608-2525
Mailing Address - Country:US
Mailing Address - Phone:973-953-9780
Mailing Address - Fax:
Practice Address - Street 1:350 S BROAD ST APT 305
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08608-2525
Practice Address - Country:US
Practice Address - Phone:973-953-9780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ884980103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool