MEDICARE: TANIAH INGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374J00000X	Doula		MI
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1174012249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANIAH INGRAM

Provider Business Mailing Address
First Line	:	1732 BENJAMIN AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5434
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1732 BENJAMIN AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5434
Country	:	US
Telephone Number	:	616-914-0795
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2018
Last Update Date	:	09/06/2024

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Directions to “ TANIAH INGRAM ” Practice Location

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