Provider Demographics
NPI:1831904069
Name:INGRAM, SHAVON C
Entity type:Individual
Prefix:
First Name:SHAVON
Middle Name:C
Last Name:INGRAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2612
Mailing Address - Country:US
Mailing Address - Phone:614-207-1083
Mailing Address - Fax:
Practice Address - Street 1:650 CARPENTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2612
Practice Address - Country:US
Practice Address - Phone:614-207-1083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-13
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH174200000X, 253Z00000X, 374U00000X, 101YM0800X, 376J00000X, 376K00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No174200000XOther Service ProvidersMeals
No253Z00000XAgenciesIn Home Supportive Care
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No376K00000XNursing Service Related ProvidersNurse's Aide
No385H00000XRespite Care FacilityRespite Care