Provider Demographics
NPI:1255468708
Name:ZACHARY, CHARLES PHILLIP JR (BS LBSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:PHILLIP
Last Name:ZACHARY
Suffix:JR
Gender:M
Credentials:BS LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40134 WINSLOW CT
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-2071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43740 N GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1139
Practice Address - Country:US
Practice Address - Phone:586-469-7817
Practice Address - Fax:586-469-7662
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802065743104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker