Provider Demographics
NPI:1740414788
Name:INGRAM, ANTHONY WAYNE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:WAYNE
Last Name:INGRAM
Suffix:
Gender:M
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6009 SEA RANCH DR
Mailing Address - Street 2:APT. 302
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-4545
Mailing Address - Country:US
Mailing Address - Phone:954-591-2520
Mailing Address - Fax:
Practice Address - Street 1:6009 SEA RANCH DR
Practice Address - Street 2:APT. 302
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-4545
Practice Address - Country:US
Practice Address - Phone:954-591-2520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 13188225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist