Provider Demographics
NPI:1497970180
Name:WACKERLY, DANA R (PHD)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:R
Last Name:WACKERLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3445 AMERICAN RIVER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-5744
Mailing Address - Country:US
Mailing Address - Phone:916-973-8928
Mailing Address - Fax:916-974-1867
Practice Address - Street 1:3445 AMERICAN RIVER DR
Practice Address - Street 2:SUITE B
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95864-5744
Practice Address - Country:US
Practice Address - Phone:916-973-8928
Practice Address - Fax:916-974-1867
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14648103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL14648Medicare ID - Type Unspecified