Healthcare Provider Details

I. General information

NPI: 1477969707
Provider Name (Legal Business Name): BRANDY LATASHA INGRAM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRANDY LATASHA HICKS

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5868 CREEK STATION DR
PENSACOLA FL
32504-8627
US

IV. Provider business mailing address

5868 CREEK STATION DR
PENSACOLA FL
32504-8627
US

V. Phone/Fax

Practice location:
  • Phone: 850-478-1244
  • Fax:
Mailing address:
  • Phone: 850-478-1244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW12467
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: