Basic Information
Provider Information | |||||||||
NPI: | 1275744898 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BETH INGRAM & ASSOCIATES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 602 VONDERBURG DR | ||||||||
Address2: | SUITE 201 | ||||||||
City: | BRANDON | ||||||||
State: | FL | ||||||||
PostalCode: | 335115900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136531149 | ||||||||
FaxNumber: | 8136546644 | ||||||||
Practice Location | |||||||||
Address1: | 1344 W FLETCHER AVE | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336123366 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136531149 | ||||||||
FaxNumber: | 8136546644 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/25/2007 | ||||||||
LastUpdateDate: | 03/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MANNSCHRECK | ||||||||
AuthorizedOfficialFirstName: | REBEKAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8136531149 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.S., C.C.C. | ||||||||
NPICertificationDate: | 03/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 222Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |   | 225X00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 235Z00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | ER761A | 01 | FL | MEDICARE PTAN | OTHER | 880065102 | 05 | FL |   | MEDICAID | 880065104 | 05 | FL |   | MEDICAID | 880065105 | 05 | FL |   | MEDICAID | 000780900 | 05 | FL |   | MEDICAID | 880065100 | 05 | FL |   | MEDICAID | 880065107 | 05 | FL |   | MEDICAID |