Provider Demographics
NPI:1912768912
Name:INGRAM, LATORIA
Entity type:Individual
Prefix:
First Name:LATORIA
Middle Name:
Last Name:INGRAM
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 1:1207 WALTER REED RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4437
Mailing Address - Country:US
Mailing Address - Phone:910-987-6758
Mailing Address - Fax:
Practice Address - Street 1:1207 WALTER REED RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4437
Practice Address - Country:US
Practice Address - Phone:910-987-6758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-17
Last Update Date:2025-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA21125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health