Provider Demographics
NPI:1245634336
Name:INGRAHAM, SCOTT DAVID (OTR/L)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DAVID
Last Name:INGRAHAM
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 W LONGVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1061
Mailing Address - Country:US
Mailing Address - Phone:614-832-7364
Mailing Address - Fax:
Practice Address - Street 1:54 W LONGVIEW AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43202-1061
Practice Address - Country:US
Practice Address - Phone:614-832-7364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT.008780172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker