Provider Demographics
NPI:1548637176
Name:INGALLS, MICAH
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:INGALLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3082 W MAPLE LOOP DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5797
Mailing Address - Country:US
Mailing Address - Phone:385-254-3522
Mailing Address - Fax:
Practice Address - Street 1:3082 W MAPLE LOOP DR STE 200
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-5797
Practice Address - Country:US
Practice Address - Phone:385-254-3522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9534465-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist