Provider Demographics
NPI:1003011495
Name:BRACKMANN, DOUGLAS (PHD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:BRACKMANN
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 1:8536 RIDGEFIELD PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-3731
Mailing Address - Country:US
Mailing Address - Phone:858-735-1667
Mailing Address - Fax:619-542-0332
Practice Address - Street 1:3101 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5802
Practice Address - Country:US
Practice Address - Phone:858-735-1667
Practice Address - Fax:619-542-0332
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19753103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist