Basic Information
| Provider Information | |||||||||
| NPI: | 1770811291 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | INGRAM | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | BORDEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7035 95TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794247546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853909743 | ||||||||
| FaxNumber: | 8286319280 | ||||||||
| Practice Location | |||||||||
| Address1: | 154 MEDICAL PARK LOOP | ||||||||
| Address2: | |||||||||
| City: | SYLVA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287795271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286313973 | ||||||||
| FaxNumber: | 8286319280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2009 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 3879 | NC | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | 38492 | TX | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.