Provider Demographics
NPI:1932210333
Name:INGRAM, NICOLA (MSW)
Entity Type:Individual
Prefix:
First Name:NICOLA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W LEAMY AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-2312
Mailing Address - Country:US
Mailing Address - Phone:610-328-2320
Mailing Address - Fax:
Practice Address - Street 1:112 W LEAMY AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-2312
Practice Address - Country:US
Practice Address - Phone:610-328-2320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0139301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0729240000OtherIBC
PA7308101OtherAETNA
PA172982000OtherKEYSTONE
PA0729240000OtherIBC