MEDICARE: DR. MARK D ACKERMAN PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	1647	GA

General Provider Information

NPI Number	:	1376651653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK D ACKERMAN PHD

Provider Business Mailing Address
First Line	:	PO BOX 888213
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30356-0213
Country	:	US
Telephone Number	:	404-428-1887
Fax Number	:

Provider Business Practice Location Address
First Line	:	3280 HOWELL MILL RD NW
Second Line	:	217 E
City	:	ATLANTA
State	:	GA
Zip	:	30327-4111
Country	:	US
Telephone Number	:	404-428-1887
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2006
Last Update Date	:	07/08/2007

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