Provider Demographics
NPI:1093295024
Name:ZAVALA, ALONZO CHAZ (RBT)
Entity Type:Individual
Prefix:
First Name:ALONZO
Middle Name:CHAZ
Last Name:ZAVALA
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:ALONZO
Other - Middle Name:
Other - Last Name:ZAVALA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RBT
Mailing Address - Street 1:W3349 COUNTY ROAD NN
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-4422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W3349 COUNTY ROAD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4422
Practice Address - Country:US
Practice Address - Phone:815-388-5841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1861576Medicaid