1649413766 NPI number — MRS. JUDITH BRANTLEY INGHRAM BCBA

Table of content: MRS. JUDITH BRANTLEY INGHRAM BCBA (NPI 1649413766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649413766 NPI number — MRS. JUDITH BRANTLEY INGHRAM BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
INGHRAM
Provider First Name:
JUDITH
Provider Middle Name:
BRANTLEY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRANTLEY
Provider Other First Name:
JUDITH
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649413766
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1470 ROLLING RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM HARBOR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34683-2825
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-460-4968
Provider Business Mailing Address Fax Number:
727-771-7371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1470 ROLLING RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM HARBOR
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34683-2825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-460-4968
Provider Business Practice Location Address Fax Number:
727-771-7371
Provider Enumeration Date:
04/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1-03-1324 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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