Healthcare Provider Details

I. General information

NPI: 1215678479
Provider Name (Legal Business Name): STEPHAN HARDIN-INGRAM MA, APCC, NCC, CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2022
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5998 ALCALA PARK RM 215
SAN DIEGO CA
92110-8001
US

IV. Provider business mailing address

5998 ALCALA PARK RM 215
SAN DIEGO CA
92110-8001
US

V. Phone/Fax

Practice location:
  • Phone: 760-450-8731
  • Fax:
Mailing address:
  • Phone: 760-450-8731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC23200
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberTCH188802
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: