Healthcare Provider Details

I. General information

NPI: 1205550316
Provider Name (Legal Business Name): MR. BENJAMIN W. J. INGRAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2528 NW 109TH ST
OKLAHOMA CITY OK
73120-7118
US

IV. Provider business mailing address

2528 NW 109TH ST
OKLAHOMA CITY OK
73120-7118
US

V. Phone/Fax

Practice location:
  • Phone: 405-981-7091
  • Fax: 405-228-7047
Mailing address:
  • Phone: 405-981-7091
  • Fax: 405-228-7047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: