Provider Demographics
NPI:1952709529
Name:ACKLEY, CARROLL L (LADC, CCS)
Entity type:Individual
Prefix:MR
First Name:CARROLL
Middle Name:L
Last Name:ACKLEY
Suffix:
Gender:M
Credentials:LADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 DOWD RD
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6700
Mailing Address - Country:US
Mailing Address - Phone:207-947-6800
Mailing Address - Fax:207-947-6872
Practice Address - Street 1:74 DOWD RD
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6700
Practice Address - Country:US
Practice Address - Phone:207-947-6800
Practice Address - Fax:207-947-6872
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC1222261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone