Provider Demographics
NPI:1952411910
Name:INGRAM, BETH MARIE (MFT)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:MARIE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3164 CONDO CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2557
Mailing Address - Country:US
Mailing Address - Phone:707-360-1900
Mailing Address - Fax:707-523-0133
Practice Address - Street 1:341 IRWIN LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5603
Practice Address - Country:US
Practice Address - Phone:707-576-7218
Practice Address - Fax:707-576-7243
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29342106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC29342OtherMARRIAGE/FAMILY THERAPIST