Provider Demographics
NPI:1891961124
Name:INGRAM, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 CODDINGTOWN CTR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-3537
Mailing Address - Country:US
Mailing Address - Phone:707-565-7649
Mailing Address - Fax:
Practice Address - Street 1:1300 CODDINGTOWN CTR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-3537
Practice Address - Country:US
Practice Address - Phone:707-565-7649
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-06
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)