Provider Demographics
NPI:1720569726
Name:INGRAM COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:INGRAM COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCPC/COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-722-8281
Mailing Address - Street 1:1161 FORTUNE BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7385
Mailing Address - Country:US
Mailing Address - Phone:314-722-8281
Mailing Address - Fax:618-206-8476
Practice Address - Street 1:1161 FORTUNE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-7385
Practice Address - Country:US
Practice Address - Phone:314-722-8281
Practice Address - Fax:618-206-8476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.010041261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)