Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003186826 |
---|---|
Provider Name | Phillip Ingersoll |
First Address | Noble, OK 73068-8473 |
Second Address | Noble, OK 73068-8473 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/01/2012 |
Last Update Date | 10/01/2012 |