Provider Demographics
NPI:1972687358
Name:ACKERMAN, MARC J (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:J
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5800 N BAYSHORE DRIVE
Mailing Address - Street 2:A 250
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4536
Mailing Address - Country:US
Mailing Address - Phone:414-962-6764
Mailing Address - Fax:414-962-6765
Practice Address - Street 1:5800 N BAYSHORE DRIVE
Practice Address - Street 2:A 250
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4536
Practice Address - Country:US
Practice Address - Phone:414-962-6764
Practice Address - Fax:414-962-6765
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI506057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39052800Medicaid