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General NPI Number Information
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NPI Number | 1720569726
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Entity Type | Organization
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Legal Business Name | INGRAM COUNSELING SERVICES, LLC
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Dates
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Enumeration Date | 08/27/2018
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Last Update Date | 08/27/2018
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Provider Practice Location Address
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Address Line | 1161 FORTUNE BLVD STE 400
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City | SHILOH
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State | IL
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Zip | 62269-7385
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Country | US
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Telephone | 314-722-8281
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Fax | 618-206-8476
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Provider Business Mailing Address
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Address Line | 1161 FORTUNE BLVD STE 400
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City | SHILOH
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State | IL
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Zip | 62269-7385
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Country | US
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Telephone | 314-722-8281
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Fax | 618-206-8476
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Authorized Official
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Title or Position | LCPC/COUNSELOR
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Name | ANGELA M INGRAM
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Credential |
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Telephone | 314-722-8281
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 180.010041
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License Number State | IL
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