Provider Demographics
NPI:1407890114
Name:ACKERMAN, CHARLOTTE (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 ELK CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-552-0920
Mailing Address - Fax:208-529-2564
Practice Address - Street 1:1522 ELK CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-552-0920
Practice Address - Fax:208-529-2564
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-6021041C0700X
IDLMFT-2965106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1690763Medicare ID - Type Unspecified