Basic Information
| Provider Information | |||||||||
| NPI: | 1225786296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INGRAM | ||||||||
| FirstName: | DETRAVEUS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CADC-R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 377 NEEDMORE RD | ||||||||
| Address2: | |||||||||
| City: | CARTHAGE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283279245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106382134 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 PAGE DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102359090 | ||||||||
| FaxNumber: | 9102359093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2022 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CADC-27212 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.