Provider Demographics
NPI:1023539475
Name:ZACK, CASEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:
Last Name:ZACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21633 AVENUE 24
Mailing Address - Street 2:
Mailing Address - City:CHOWCHILLA
Mailing Address - State:CA
Mailing Address - Zip Code:93610-9650
Mailing Address - Country:US
Mailing Address - Phone:559-665-6100
Mailing Address - Fax:
Practice Address - Street 1:21633 AVENUE 24
Practice Address - Street 2:
Practice Address - City:CHOWCHILLA
Practice Address - State:CA
Practice Address - Zip Code:93610-9650
Practice Address - Country:US
Practice Address - Phone:559-665-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103G00000X, 103T00000X, 103TF0200X
CAPSY29850103G00000X, 103TF0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic