Provider Demographics
NPI:1972513901
Name:INGRAHAM, CAROLYN A (PT)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:A
Last Name:INGRAHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4923 US ROUTE 5
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:VT
Mailing Address - Zip Code:05158
Mailing Address - Country:US
Mailing Address - Phone:802-722-4023
Mailing Address - Fax:802-722-4137
Practice Address - Street 1:4923 US ROUTE 5
Practice Address - Street 2:SOJOURNS COMMUNITY HEALTH CLINIC
Practice Address - City:WESTMINSTER
Practice Address - State:VT
Practice Address - Zip Code:05158
Practice Address - Country:US
Practice Address - Phone:802-722-4023
Practice Address - Fax:802-722-4137
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400003171225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11325860OtherCAQH
VT1010414Medicaid
VT59856OtherBCBS
11325860OtherCAQH