Provider Demographics
NPI:1053787184
Name:INGHAM, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:INGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8527 MAYLAND DR
Mailing Address - Street 2:101
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23294-4753
Mailing Address - Country:US
Mailing Address - Phone:804-346-5165
Mailing Address - Fax:804-346-5167
Practice Address - Street 1:8527 MAYLAND DR
Practice Address - Street 2:101
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4753
Practice Address - Country:US
Practice Address - Phone:804-346-5165
Practice Address - Fax:804-346-5167
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040091111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical