Provider Demographics
NPI:1205599420
Name:INGO, KAILEY
Entity type:Individual
Prefix:
First Name:KAILEY
Middle Name:
Last Name:INGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ELFORD CT
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29306-3250
Mailing Address - Country:US
Mailing Address - Phone:864-676-0028
Mailing Address - Fax:864-476-0033
Practice Address - Street 1:424 HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:LANDRUM
Practice Address - State:SC
Practice Address - Zip Code:29356-8980
Practice Address - Country:US
Practice Address - Phone:864-676-0028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-21-181646106S00000X
SC1-23-69362103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNRBT-21-181646OtherBACBC