Provider Demographics
NPI:1992887079
Name:INGRAM, C. LOUISE (LCSW)
Entity type:Individual
Prefix:
First Name:C.
Middle Name:LOUISE
Last Name:INGRAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10455 WHITE GRANITE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OAKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22124-2764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10455 WHITE GRANITE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:OAKTON
Practice Address - State:VA
Practice Address - Zip Code:22124-2764
Practice Address - Country:US
Practice Address - Phone:703-219-2166
Practice Address - Fax:703-219-3856
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040048381041C0700X
NCC0036451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical