1043757925 NPI number — ACACIA PSYCHOLOGICAL CORPORATION

Table of content: (NPI 1043757925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043757925 NPI number — ACACIA PSYCHOLOGICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACACIA PSYCHOLOGICAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043757925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
948 EMBARCADERO DEL NORTE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOLETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93117-5106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2720 UNIVERSITY AVE SE
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55414-3210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-399-2511
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DONNELLY
Authorized Official First Name:
BRETT
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER/CEO
Authorized Official Telephone Number:
805-399-2511

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  CC01316 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X , with the licence number: GL0058 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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