Provider Demographics
NPI:1770811291
Name:INGRAM, PAUL BORDEN IV (PHD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:BORDEN
Last Name:INGRAM
Suffix:IV
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7035 95TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-7546
Mailing Address - Country:US
Mailing Address - Phone:785-390-9743
Mailing Address - Fax:828-631-9280
Practice Address - Street 1:154 MEDICAL PARK LOOP
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-5271
Practice Address - Country:US
Practice Address - Phone:828-631-3973
Practice Address - Fax:828-631-9280
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3879103T00000X
TX38492103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist