Provider Demographics
NPI:1194982397
Name:INGRAM, DANA (NCC, LPC)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:NCC, LPC
Other - Prefix:
Other - First Name:DANA
Other - Middle Name:
Other - Last Name:WAGONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 245
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:AR
Mailing Address - Zip Code:72556-0245
Mailing Address - Country:US
Mailing Address - Phone:870-300-2112
Mailing Address - Fax:844-377-1447
Practice Address - Street 1:31 SCHOOL DR STE B
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:AR
Practice Address - Zip Code:72556-8620
Practice Address - Country:US
Practice Address - Phone:870-300-2112
Practice Address - Fax:844-377-1447
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1305051101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR227890719Medicaid