Provider Demographics
NPI:1649342338
Name:ACKERMAN, THOMAS DIEDEN (MSW)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:DIEDEN
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N4382 TUCKER WAY DR
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-6644
Mailing Address - Country:US
Mailing Address - Phone:715-284-0972
Mailing Address - Fax:
Practice Address - Street 1:2925 MONDOVI RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6141
Practice Address - Country:US
Practice Address - Phone:715-832-0238
Practice Address - Fax:715-832-0771
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6547-123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI105505OtherSECURITY HEALTH PLAN #
WI6547-123OtherSTATE MSW LICENSE #
WI39759400Medicaid