=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184064891
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUDITHE LOUIS-INGRAM LCSWA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2013
-----------------------------------------------------
Last Update Date | 12/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 W MAIN ST STE 316
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27701-3228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-230-1263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 PARK RD STE 218B
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28209-3650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-700-1606
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | P018933
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------