Provider Demographics
NPI:1205550316
Name:INGRAM, BENJAMIN W J
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:W J
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 1:2528 NW 109TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-7118
Mailing Address - Country:US
Mailing Address - Phone:405-981-7091
Mailing Address - Fax:405-228-7047
Practice Address - Street 1:2528 NW 109TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-7118
Practice Address - Country:US
Practice Address - Phone:405-981-7091
Practice Address - Fax:405-228-7047
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKEF999447760OtherNONE