Provider Demographics
NPI:1306181029
Name:TEDDER, ZACKERY ALEXANDER (MA, LPA)
Entity Type:Individual
Prefix:MR
First Name:ZACKERY
Middle Name:ALEXANDER
Last Name:TEDDER
Suffix:
Gender:M
Credentials:MA, LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 FORTVIEW RD STE 101
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7654
Mailing Address - Country:US
Mailing Address - Phone:512-271-7628
Mailing Address - Fax:
Practice Address - Street 1:1825 FORTVIEW RD STE 101
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7654
Practice Address - Country:US
Practice Address - Phone:512-271-7628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-06
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36417101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health