Provider Demographics
NPI:1033665906
Name:ACKERMAN, KATHLEEN TERESA (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:TERESA
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1848
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:468 CADIEUX RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1507
Practice Address - Country:US
Practice Address - Phone:313-473-6899
Practice Address - Fax:313-473-1509
Is Sole Proprietor?:No
Enumeration Date:2016-08-30
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant