MEDICARE: BRANDY D ACKER PH.D

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	103T00000X	Psychologist	37845	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	37845	OTHER	TX	PROVISIONALLY LICENSED PSYCHOLOGIST

General Provider Information

NPI Number	:	1821583501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY D ACKER PH.D

Provider Business Mailing Address
First Line	:	3515 RICHMOND RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-0711
Country	:	US
Telephone Number	:	903-791-9355
Fax Number	:	903-793-0496

Provider Business Practice Location Address
First Line	:	3615 RICHMOND RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503
Country	:	US
Telephone Number	:	903-791-9355
Fax Number	:

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

Provider Enumeration Date	:	06/26/2018
Last Update Date	:	02/06/2020

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