Provider Demographics
NPI:1356814115
Name:GACKOWSKI, IAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:
Last Name:GACKOWSKI
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 ARBOR CIR W APT 108
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-3450
Mailing Address - Country:US
Mailing Address - Phone:269-370-1868
Mailing Address - Fax:
Practice Address - Street 1:120 E LIBERTY ST STE 300D
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2163
Practice Address - Country:US
Practice Address - Phone:269-370-1868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017272103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist