Provider Demographics
NPI:1114948098
Name:ZACK, STEPHANIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:ZACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-2810
Mailing Address - Country:US
Mailing Address - Phone:530-340-1836
Mailing Address - Fax:530-842-3467
Practice Address - Street 1:412 W CENTER ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-2810
Practice Address - Country:US
Practice Address - Phone:530-340-1836
Practice Address - Fax:530-842-3467
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALC125511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ017337Medicare ID - Type Unspecified