Provider Demographics
NPI:1649413766
Name:INGHRAM, JUDITH BRANTLEY (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:BRANTLEY
Last Name:INGHRAM
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:MARIE
Other - Last Name:BRANTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1470 ROLLING RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-2825
Mailing Address - Country:US
Mailing Address - Phone:727-460-4968
Mailing Address - Fax:727-771-7371
Practice Address - Street 1:1470 ROLLING RIDGE RD
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-2825
Practice Address - Country:US
Practice Address - Phone:727-460-4968
Practice Address - Fax:727-771-7371
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-03-1324103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst