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General NPI Number Information
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NPI Number | 1801312830
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Entity Type | Individual
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Provider Name | MRS. TAKEISHA MITCHELL-INGRAM
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Gender | Female
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Dates
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Enumeration Date | 08/22/2017
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Last Update Date | 08/22/2017
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Provider Practice Location Address
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Address Line | 130 S INDIAN RIVER DR STE 202
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City | FORT PIERCE
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State | FL
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Zip | 34950-4353
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Country | US
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Telephone | 772-905-9030
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Fax |
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Provider Business Mailing Address
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Address Line | 1778 SW NEWPORT ISLES BLVD
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City | PORT ST LUCIE
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State | FL
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Zip | 34953-4590
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Country | US
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Telephone | 561-818-1101
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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 | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number |
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License Number State |
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