Provider Demographics
NPI:1427693126
Name:INGRAM, SUSAN RENAE (LPTA)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:RENAE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 GOSHAWK LN
Mailing Address - Street 2:
Mailing Address - City:FARINA
Mailing Address - State:IL
Mailing Address - Zip Code:62838-3734
Mailing Address - Country:US
Mailing Address - Phone:618-292-4655
Mailing Address - Fax:
Practice Address - Street 1:911 STACEY BURK DR
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-3241
Practice Address - Country:US
Practice Address - Phone:618-292-4655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-17
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160-003878225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant