Basic Information
| Provider Information | |||||||||
| NPI: | 1437360054 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BETH INGRAM & ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 VONDERBURG DR | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136531149 | ||||||||
| FaxNumber: | 8136546644 | ||||||||
| Practice Location | |||||||||
| Address1: | 1818 HARDEN BLVD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338031812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136531149 | ||||||||
| FaxNumber: | 8136546644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| AuthorizedOfficialLastName: | MANNSCHRECK | ||||||||
| AuthorizedOfficialFirstName: | REBEKAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8136531149 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, CCC-SLP | ||||||||
| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical 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 | 880065104 | 05 | FL | MEDICAID | 000780900 | 05 | FL | MEDICAID | 880065100 | 05 | FL | MEDICAID | 880065102 | 05 | FL | MEDICAID | 880065105 | 05 | FL | MEDICAID | 880065107 | 05 | FL | MEDICAID | ER761A | 01 | FL | MEDICARE PTAN | OTHER |