Provider Demographics
NPI:1891251047
Name:INGRAM, SKYLEA NICOLE
Entity Type:Individual
Prefix:
First Name:SKYLEA
Middle Name:NICOLE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SKYLEA
Other - Middle Name:NICOLE
Other - Last Name:BURROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2919 BREEZEWOOD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5283
Mailing Address - Country:US
Mailing Address - Phone:910-484-1711
Mailing Address - Fax:
Practice Address - Street 1:3649 CAPE CENTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4457
Practice Address - Country:US
Practice Address - Phone:910-484-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-13
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-23-290290106S00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician