Provider Demographics
NPI:1013392752
Name:ACKLIN, ABRAHAM ISAAC
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:ISAAC
Last Name:ACKLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10935 TERRA VISTA PKWY APT 181
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6356
Mailing Address - Country:US
Mailing Address - Phone:909-248-8453
Mailing Address - Fax:
Practice Address - Street 1:201 REDLANDS AVE
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2600
Practice Address - Country:US
Practice Address - Phone:951-940-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-23
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker