Provider Demographics
NPI:1366125551
Name:ACKERMAN, ROGER LYN
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:LYN
Last Name:ACKERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 CLEMANS VIEW RD
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-9074
Mailing Address - Country:US
Mailing Address - Phone:509-317-3900
Mailing Address - Fax:
Practice Address - Street 1:611 W A ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2605
Practice Address - Country:US
Practice Address - Phone:509-452-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61184506101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)