Provider Demographics
NPI:1881365583
Name:INGRAM, EBONY ELISE
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:ELISE
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 1:400 ESTUDILLO AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4962
Mailing Address - Country:US
Mailing Address - Phone:510-924-0548
Mailing Address - Fax:
Practice Address - Street 1:426 17TH ST STE 2
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2820
Practice Address - Country:US
Practice Address - Phone:510-433-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator