Provider Demographics
NPI:1902814494
Name:INGRAM, AMBER STAMENT (MPT)
Entity Type:Individual
Prefix:MISS
First Name:AMBER
Middle Name:STAMENT
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:17051 DALLAS PKWY
Practice Address - Street 2:STE 450
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-7109
Practice Address - Country:US
Practice Address - Phone:214-272-8561
Practice Address - Fax:469-941-4002
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1162048225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D9502Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER