=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477211175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INGRAM COUNSELING & CONSULTING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2021
-----------------------------------------------------
Last Update Date | 12/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6034 RIVER LAKE CIR
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27604-6000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-877-6442
-----------------------------------------------------
Fax | 919-887-0479
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 958
-----------------------------------------------------
City | KNIGHTDALE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27545-0958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-877-6442
-----------------------------------------------------
Fax | 919-887-0479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TACARRA INGRAM
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 919-877-6442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------