Provider Demographics
NPI:1588310619
Name:INGRAM, ELESIA
Entity type:Individual
Prefix:
First Name:ELESIA
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELESIA
Other - Middle Name:
Other - Last Name:BURTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1535 E SHELBY DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-7224
Mailing Address - Country:US
Mailing Address - Phone:901-498-3118
Mailing Address - Fax:
Practice Address - Street 1:1125 SCHILLING BLVD E
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-7078
Practice Address - Country:US
Practice Address - Phone:901-248-7440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician