Provider Demographics
NPI:1912020876
Name:GARY D. ACKERLEY, INC.
Entity Type:Organization
Organization Name:GARY D. ACKERLEY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ACKERLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,ABPP
Authorized Official - Phone:937-640-1432
Mailing Address - Street 1:305 E STROOP RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2827
Mailing Address - Country:US
Mailing Address - Phone:937-640-1432
Mailing Address - Fax:937-294-3320
Practice Address - Street 1:305 E STROOP RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2827
Practice Address - Country:US
Practice Address - Phone:937-640-1432
Practice Address - Fax:937-294-3320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2853103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6159301OtherUNITED HEALTH CARE
OH000000328814OtherANTHEM BCBS
OH6159301OtherUNITED HEALTH CARE