=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215622337
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYNDE ACKS, PSY.D, PROFESSIONAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2023
-----------------------------------------------------
Last Update Date | 05/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 PETALUMA AVE STE 136
-----------------------------------------------------
City | SEBASTOPOL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95472-4273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-387-0245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 435 PETALUMA AVE STE 136
-----------------------------------------------------
City | SEBASTOPOL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95472-4273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-387-0245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CYNTHIA LYNNE ACKS-STEWART
-----------------------------------------------------
Credential | PSY. D
-----------------------------------------------------
Telephone | 707-480-7119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------