Provider Demographics
NPI:1093593477
Name:CHACON, INGRID IDA (AMFT)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:IDA
Last Name:CHACON
Suffix:
Gender:
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 E BRANCH ST
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-2804
Mailing Address - Country:US
Mailing Address - Phone:951-599-3739
Mailing Address - Fax:
Practice Address - Street 1:212 CARMEN LN
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-7769
Practice Address - Country:US
Practice Address - Phone:805-212-7680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA151226106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health