Provider Demographics
NPI:1922297787
Name:INGRAM, GREGORY (LICSW)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:ROEATHEA
Other - Middle Name:
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:6856 EASTERN AVE NW
Mailing Address - Street 2:286
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-2165
Mailing Address - Country:US
Mailing Address - Phone:202-723-6600
Mailing Address - Fax:202-723-2549
Practice Address - Street 1:8506 SCHULTZ RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2662
Practice Address - Country:US
Practice Address - Phone:202-297-9992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2019-03-12
Deactivation Date:2019-03-05
Deactivation Code:
Reactivation Date:2019-03-12
Provider Licenses
StateLicense IDTaxonomies
DCLG102351104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker