Provider Demographics
NPI:1336442524
Name:INGHAM, JOANN MARIE (MS, PT)
Entity Type:Individual
Prefix:MRS
First Name:JOANN
Middle Name:MARIE
Last Name:INGHAM
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:MISS
Other - First Name:JOANN
Other - Middle Name:MARIE
Other - Last Name:HOLLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PT
Mailing Address - Street 1:2495 MAIN ST
Mailing Address - Street 2:SUITE 234
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-2152
Mailing Address - Country:US
Mailing Address - Phone:716-836-5929
Mailing Address - Fax:716-836-6057
Practice Address - Street 1:2495 MAIN ST
Practice Address - Street 2:SUITE 234
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2152
Practice Address - Country:US
Practice Address - Phone:716-836-5929
Practice Address - Fax:716-836-6057
Is Sole Proprietor?:No
Enumeration Date:2010-12-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014239-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics