Provider Demographics
NPI:1982331468
Name:INGRAM, RODNEY LAMAR (OTPT)
Entity Type:Individual
Prefix:MR
First Name:RODNEY
Middle Name:LAMAR
Last Name:INGRAM
Suffix:
Gender:M
Credentials:OTPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 SPY GLASS DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-6966
Mailing Address - Country:US
Mailing Address - Phone:910-578-7602
Mailing Address - Fax:
Practice Address - Street 1:731 TILGHMAN DR
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-5507
Practice Address - Country:US
Practice Address - Phone:910-249-4219
Practice Address - Fax:866-279-1991
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P0174161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty