Provider Demographics
NPI:1043757925
Name:ACACIA PSYCHOLOGICAL CORPORATION
Entity Type:Organization
Organization Name:ACACIA PSYCHOLOGICAL CORPORATION
Other - Org Name:ACACIA COUNSELING & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-399-2511
Mailing Address - Street 1:948 EMBARCADERO DEL NORTE
Mailing Address - Street 2:
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-5106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2720 UNIVERSITY AVE SE
Practice Address - Street 2:UNIT B
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3210
Practice Address - Country:US
Practice Address - Phone:805-399-2511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-30
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01316101YP2500X
MNGL0058103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty