Provider Demographics
NPI:1750582946
Name:INGRAM-WALLACE, BRENDA J (PHD)
Entity type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:J
Last Name:INGRAM-WALLACE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13736
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3736
Mailing Address - Country:US
Mailing Address - Phone:610-921-7585
Mailing Address - Fax:610-929-6697
Practice Address - Street 1:1401 UNION STREET
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19604
Practice Address - Country:US
Practice Address - Phone:610-921-7585
Practice Address - Fax:610-929-6697
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS006970L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical