Provider Demographics
NPI:1023627213
Name:INGRAM, KUANTARA SHORELL (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KUANTARA
Middle Name:SHORELL
Last Name:INGRAM
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 SWEETWATER RD APT 3202
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-8511
Mailing Address - Country:US
Mailing Address - Phone:334-296-5421
Mailing Address - Fax:
Practice Address - Street 1:5373 THOMPSON MILL RD
Practice Address - Street 2:
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548-4037
Practice Address - Country:US
Practice Address - Phone:770-965-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP011098235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist