Provider Demographics
NPI:1679994297
Name:ACKERMAN, SHELLEY
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 GRIM AVE
Mailing Address - Street 2:APT 8
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-3650
Mailing Address - Country:US
Mailing Address - Phone:786-344-3221
Mailing Address - Fax:
Practice Address - Street 1:3711 GRIM AVE
Practice Address - Street 2:APT 8
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-3650
Practice Address - Country:US
Practice Address - Phone:786-344-3221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-27
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT40922225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist