Provider Demographics
NPI:1467527101
Name:ACKERMAN, BRIAN LEE (PT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:LEE
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 58TH ST S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-5257
Mailing Address - Country:US
Mailing Address - Phone:419-351-5423
Mailing Address - Fax:
Practice Address - Street 1:10099 SEMINOLE BLVD
Practice Address - Street 2:SUITE 5A
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33772-2521
Practice Address - Country:US
Practice Address - Phone:727-399-8226
Practice Address - Fax:727-393-4823
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5225225100000X
FLPT23549225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist