Provider Demographics
NPI:1417692625
Name:INGRAM, CHAQUITA (COUNSELOR)
Entity type:Individual
Prefix:
First Name:CHAQUITA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 SOMERSET DR APT Z307
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33311-9475
Mailing Address - Country:US
Mailing Address - Phone:561-709-9436
Mailing Address - Fax:
Practice Address - Street 1:2690 SOMERSET DR APT Z307
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33311-9475
Practice Address - Country:US
Practice Address - Phone:561-709-9436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFTCA-CLI-1024-430101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFTCA-CLI-1024-430OtherPASTORAL LICENSE