Healthcare Provider Details

I. General information

NPI: 1992377758
Provider Name (Legal Business Name): HANNAH MARIE INGERSOLL MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 GILMAN DR
LA JOLLA CA
92093-5004
US

IV. Provider business mailing address

PO BOX 151240
SAN DIEGO CA
92175-1240
US

V. Phone/Fax

Practice location:
  • Phone: 619-787-0609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: