Provider Demographics
NPI:1124457130
Name:INGRAM, ELISA SHAWANN (BCBA, LBA)
Entity type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:SHAWANN
Last Name:INGRAM
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 HUDSON LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-8603
Mailing Address - Country:US
Mailing Address - Phone:210-240-6186
Mailing Address - Fax:
Practice Address - Street 1:500 FAIRWAY DR
Practice Address - Street 2:SUITE 102
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33441-1814
Practice Address - Country:US
Practice Address - Phone:954-603-7885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-11
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist