Basic Information
Provider Information | |||||||||
NPI: | 1134446982 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | INGRAM | ||||||||
FirstName: | SHAYE | ||||||||
MiddleName: | LYNNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS.CCC/SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6417 SHAWNEE | ||||||||
Address2: |   | ||||||||
City: | MIDLAND | ||||||||
State: | TX | ||||||||
PostalCode: | 79705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4324132243 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 620 N ALLEGHANEY AVE | ||||||||
Address2: |   | ||||||||
City: | ODESSA | ||||||||
State: | TX | ||||||||
PostalCode: | 797614408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4323328244 | ||||||||
FaxNumber: | 4325807428 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2010 | ||||||||
LastUpdateDate: | 05/03/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 104418 | TX | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 104418 | 01 | TX | LICENSE NUMBER | OTHER |