Healthcare Provider Details

I. General information

NPI: 1346178050
Provider Name (Legal Business Name): TIFFANY MONIQUE INGRAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 BROOKVIEW HILLS BLVD STE 205
WINSTON SALEM NC
27103-5661
US

IV. Provider business mailing address

3333 BROOKVIEW HILLS BLVD STE 205
WINSTON SALEM NC
27103-5661
US

V. Phone/Fax

Practice location:
  • Phone: 336-261-6440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA22783
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: