Basic Information
| Provider Information | |||||||||
| NPI: | 1003011495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRACKMANN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8536 RIDGEFIELD PL | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921293731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587351667 | ||||||||
| FaxNumber: | 6195420332 | ||||||||
| Practice Location | |||||||||
| Address1: | 3101 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921035802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587351667 | ||||||||
| FaxNumber: | 6195420332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PSY19753 | CA | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.