Basic Information
| Provider Information | |||||||||
| NPI: | 1376852905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACKERMAN | ||||||||
| FirstName: | CLAIRE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 715194 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432715194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558004 | ||||||||
| FaxNumber: | 6143550509 | ||||||||
| Practice Location | |||||||||
| Address1: | 6435 E BROAD ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432131507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558160 | ||||||||
| FaxNumber: | 6143558180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2010 | ||||||||
| LastUpdateDate: | 08/23/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 6709 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 2846675 | 05 | OH | MEDICAID |