Basic Information
| Provider Information | |||||||||
| NPI: | 1124262654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | INGULLI | ||||||||
| FirstName: | LAMAR | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2919 W SWANN AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133815200 | ||||||||
| FaxNumber: | 8133815200 | ||||||||
| Practice Location | |||||||||
| Address1: | 2919 W SWANN AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133815200 | ||||||||
| FaxNumber: | 8133815200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2009 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PY 8120 | FL | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | PY8120 | FL | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | 8120 | FL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | PY8120 | FL | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TF0200X | PY8120 | FL | N | Behavioral Health & Social Service Providers | Psychologist | Forensic | 103TM1800X | PY8120 | FL | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103G00000X | PY8120 | FL | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 007293800 | 05 | FL | MEDICAID | 020601000 | 05 | FL | MEDICAID |