MEDICARE: CRYSTAL DANIELLE 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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1518662683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL DANIELLE INGRAM

Provider Business Mailing Address
First Line	:	141 S CENTER ST STE 302
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-2543
Country	:	US
Telephone Number	:	307-274-2693
Fax Number	:

Provider Business Practice Location Address
First Line	:	141 S CENTER ST STE 302
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-2543
Country	:	US
Telephone Number	:	307-274-2693
Fax Number	:

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

Provider Enumeration Date	:	03/30/2023
Last Update Date	:	03/30/2023

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Directions to “ CRYSTAL DANIELLE INGRAM ” Practice Location

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