Provider Demographics
NPI:1740906395
Name:INGRAM, ALEXANDRIA (MA, R-DMT)
Entity type:Individual
Prefix:MRS
First Name:ALEXANDRIA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MA, R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14563 S 450 W
Mailing Address - Street 2:
Mailing Address - City:HANNA
Mailing Address - State:IN
Mailing Address - Zip Code:46340-9704
Mailing Address - Country:US
Mailing Address - Phone:219-246-0354
Mailing Address - Fax:
Practice Address - Street 1:2801 BERTHOLET BLVD STE 301
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-7959
Practice Address - Country:US
Practice Address - Phone:219-323-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300001910Medicaid