Healthcare Provider Details

I. General information

NPI: 1588915946
Provider Name (Legal Business Name): ZACHARY L INGRAM OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 UNIVERSITY AVE STE C SELLARO PLAZA
MORGANTOWN WV
26505-3205
US

IV. Provider business mailing address

625 LINCOLN AVE SUITE 107 PROFESSIONAL PLAZA
CHARLEROI PA
15022-2451
US

V. Phone/Fax

Practice location:
  • Phone: 304-241-4020
  • Fax: 304-241-4029
Mailing address:
  • Phone: 724-483-1673
  • Fax: 724-483-0290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1588
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC012445
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: