Provider Demographics
NPI:1063100634
Name:INGRAM, ALEXIS
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 FINKS HIDEAWAY RD SIDE A
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-2413
Mailing Address - Country:US
Mailing Address - Phone:318-307-1699
Mailing Address - Fax:
Practice Address - Street 1:5706 N HESPERIDES ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-5418
Practice Address - Country:US
Practice Address - Phone:813-924-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARBT-19-90459106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician