Provider Demographics
NPI:1154922201
Name:ACKERMAN, HAILEN MATTHEW
Entity type:Individual
Prefix:
First Name:HAILEN
Middle Name:MATTHEW
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 1:4725 AMBER VALLEY PKWY S STE B
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4725 AMBER VALLEY PKWY S STE B
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8614
Practice Address - Country:US
Practice Address - Phone:701-478-0221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician