Provider Demographics
NPI:1912772203
Name:INGRAM, KRISTIN KAY
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:KAY
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 171ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:HAM LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55304-4917
Mailing Address - Country:US
Mailing Address - Phone:952-454-3655
Mailing Address - Fax:
Practice Address - Street 1:1702 171ST AVE NE
Practice Address - Street 2:
Practice Address - City:HAM LAKE
Practice Address - State:MN
Practice Address - Zip Code:55304-4917
Practice Address - Country:US
Practice Address - Phone:952-454-3655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306705101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)