Provider Demographics
NPI:1053837096
Name:ACKERMAN, THAD L SR
Entity Type:Individual
Prefix:
First Name:THAD
Middle Name:L
Last Name:ACKERMAN
Suffix:SR
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 1:1291 JULIENTON DR NE
Mailing Address - Street 2:
Mailing Address - City:TOWNSEND
Mailing Address - State:GA
Mailing Address - Zip Code:31331-5011
Mailing Address - Country:US
Mailing Address - Phone:912-660-3652
Mailing Address - Fax:
Practice Address - Street 1:720 WOOD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4413
Practice Address - Country:US
Practice Address - Phone:707-268-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95108869163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health