Provider Demographics
NPI:1841011566
Name:GILBERT-INGRAM, MIA ANTONETTE (TLMHC)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:ANTONETTE
Last Name:GILBERT-INGRAM
Suffix:
Gender:F
Credentials:TLMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13802 TREGARON RIDGE AVE APT 54
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:NE
Mailing Address - Zip Code:68123-4838
Mailing Address - Country:US
Mailing Address - Phone:910-922-9036
Mailing Address - Fax:
Practice Address - Street 1:1720 N 16TH ST STE K
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-0109
Practice Address - Country:US
Practice Address - Phone:712-256-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA122839101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health