Healthcare Provider Details

I. General information

NPI: 1407890114
Provider Name (Legal Business Name): CHARLOTTE ACKERMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522 ELK CREEK DRIVE
IDAHO FALLS ID
83404
US

IV. Provider business mailing address

1522 ELK CREEK DRIVE
IDAHO FALLS ID
83404
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-0920
  • Fax: 208-529-2564
Mailing address:
  • Phone: 208-552-0920
  • Fax: 208-529-2564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-602
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT-2965
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: