Healthcare Provider Details

I. General information

NPI: 1205060894
Provider Name (Legal Business Name): CAROLYN R INGRAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 05/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 W 6TH ST
DUBUQUE IA
52001-6809
US

IV. Provider business mailing address

2005 ASBURY RD
DUBUQUE IA
52001-3042
US

V. Phone/Fax

Practice location:
  • Phone: 563-588-0605
  • Fax:
Mailing address:
  • Phone: 563-583-7357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: