Provider Demographics
NPI:1831625490
Name:INGALLS, MICAH LAURAINE (BS)
Entity type:Individual
Prefix:MRS
First Name:MICAH
Middle Name:LAURAINE
Last Name:INGALLS
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:8928 NE COUCH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-5945
Mailing Address - Country:US
Mailing Address - Phone:971-276-9639
Mailing Address - Fax:
Practice Address - Street 1:8815 S TACOMA WAY
Practice Address - Street 2:SUITE 122
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-4587
Practice Address - Country:US
Practice Address - Phone:253-682-0320
Practice Address - Fax:253-582-2901
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst