Basic Information
| Provider Information | |||||||||
| NPI: | 1154870442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACKLEY | ||||||||
| FirstName: | DONOVAN | ||||||||
| MiddleName: | WALLER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | PH.D. RADT-1 | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ACKLEY | ||||||||
| OtherFirstName: | HEATH | ||||||||
| OtherMiddleName: | ADAM | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1400 N JOHNSON AVE | ||||||||
| Address2: | 101 | ||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920201650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194420277 | ||||||||
| FaxNumber: | 6194421101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 N JOHNSON AVE | ||||||||
| Address2: | 101 | ||||||||
| City: | EL CAJON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920201650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194420277 | ||||||||
| FaxNumber: | 6194421101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2016 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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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 | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.