Provider Demographics
NPI:1942639257
Name:INGRAM, MARISSA (OTR/L)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:HOSP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA/L
Mailing Address - Street 1:6079 COLONY CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2230
Mailing Address - Country:US
Mailing Address - Phone:740-251-3752
Mailing Address - Fax:
Practice Address - Street 1:4090 BRIARGATE PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7815
Practice Address - Country:US
Practice Address - Phone:719-305-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOT.0006905225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty