Provider Demographics
NPI:1740619444
Name:INGRAM, GRANT (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6026 WINNERS CIR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-9368
Mailing Address - Country:US
Mailing Address - Phone:325-320-3204
Mailing Address - Fax:
Practice Address - Street 1:2032 W HARRIS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3806
Practice Address - Country:US
Practice Address - Phone:325-320-3204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-13-14897103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst