Provider Demographics
NPI:1790560415
Name:INGRAM, RYAN MICHAEL (PSYD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:INGRAM
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 N GENESEE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-4719
Mailing Address - Country:US
Mailing Address - Phone:660-281-8080
Mailing Address - Fax:
Practice Address - Street 1:2116 ARLINGTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-1300
Practice Address - Country:US
Practice Address - Phone:323-334-9000
Practice Address - Fax:323-334-4437
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAWAIVERED103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program