Provider Demographics
NPI:1154870442
Name:ACKLEY, DONOVAN WALLER III (PHD RADT-1)
Entity type:Individual
Prefix:DR
First Name:DONOVAN
Middle Name:WALLER
Last Name:ACKLEY
Suffix:III
Gender:M
Credentials:PHD RADT-1
Other - Prefix:
Other - First Name:HEATH
Other - Middle Name:ADAM
Other - Last Name:ACKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1400 N JOHNSON AVE
Mailing Address - Street 2:101
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1650
Mailing Address - Country:US
Mailing Address - Phone:619-442-0277
Mailing Address - Fax:619-442-1101
Practice Address - Street 1:1400 N JOHNSON AVE
Practice Address - Street 2:101
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-1650
Practice Address - Country:US
Practice Address - Phone:619-442-0277
Practice Address - Fax:619-442-1101
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)