Healthcare Provider Details

I. General information

NPI: 1205415841
Provider Name (Legal Business Name): STEVEN RAY INGRAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 12/06/2023
Certification Date: 12/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 DIXIE HWY
HAMILTON OH
45015-1653
US

IV. Provider business mailing address

100 CROWNE POINT PL
CINCINNATI OH
45241-5427
US

V. Phone/Fax

Practice location:
  • Phone: 513-892-4673
  • Fax: 513-883-1546
Mailing address:
  • Phone: 513-743-7628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCDCA184237
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.003420
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: