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General NPI Number Information
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NPI Number | 1679006118
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Entity Type | Individual
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Provider Name | COREY INGRAM LMSW
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Gender | Male
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Dates
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Enumeration Date | 04/11/2017
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Last Update Date | 04/11/2017
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Provider Practice Location Address
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Address Line | 1409 DEVINE ST
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City | COLUMBIA
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State | SC
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Zip | 29208-3902
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Country | US
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Telephone | 803-359-9871
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8745
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City | COLUMBIA
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State | SC
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Zip | 29202-8745
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Country | US
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Telephone | 803-359-9871
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 11995
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License Number State | AL
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