Provider Demographics
NPI:1073987921
Name:INGLE, SHANA
Entity type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:INGLE
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 1:1550 BECKWITH RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-5104
Mailing Address - Country:US
Mailing Address - Phone:615-582-4595
Mailing Address - Fax:615-447-5981
Practice Address - Street 1:1550 BECKWITH RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-5104
Practice Address - Country:US
Practice Address - Phone:615-582-4595
Practice Address - Fax:615-447-5981
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL000000017073320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness