Provider Demographics
NPI:1679584536
Name:ACKERLEY, GARY D (PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:D
Last Name:ACKERLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 BEVERLY PL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45419-3515
Mailing Address - Country:US
Mailing Address - Phone:937-395-9049
Mailing Address - Fax:
Practice Address - Street 1:6465 REFLECTIONS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-2355
Practice Address - Country:US
Practice Address - Phone:614-792-1108
Practice Address - Fax:614-792-0018
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2853103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0502549Medicaid
OH0502549Medicaid
OHAACP19523Medicare ID - Type Unspecified