Provider Demographics
NPI:1881852838
Name:INGRAM, IRENE ROGERS (OTR/L)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:ROGERS
Last Name:INGRAM
Suffix:
Gender:F
Credentials: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:PO BOX 1923
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1923
Mailing Address - Country:US
Mailing Address - Phone:843-332-3600
Mailing Address - Fax:843-332-1314
Practice Address - Street 1:603 W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4443
Practice Address - Country:US
Practice Address - Phone:843-332-3600
Practice Address - Fax:843-332-1314
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC34225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0118Medicaid