Healthcare Provider Details

I. General information

NPI: 1164636734
Provider Name (Legal Business Name): REBECA ACKERMAN PPSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 OTAY MESA RD
SAN YSIDRO CA
92173-1617
US

IV. Provider business mailing address

4350 OTAY MESA RD
SAN YSIDRO CA
92173-1617
US

V. Phone/Fax

Practice location:
  • Phone: 619-428-4476
  • Fax: 619-428-1393
Mailing address:
  • Phone: 619-428-4476
  • Fax: 619-428-1393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: