Provider Demographics
NPI:1255145587
Name:INGRAM, JAMES (LMT, BCTMB)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:INGRAM
Suffix:
Gender:M
Credentials:LMT, BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 WILLOW WAY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-3956
Mailing Address - Country:US
Mailing Address - Phone:301-219-5840
Mailing Address - Fax:
Practice Address - Street 1:6408 GROVEDALE DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-2595
Practice Address - Country:US
Practice Address - Phone:703-967-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019014572225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist