Provider Demographics
NPI:1467059683
Name:ZIMMER, IAN K
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:K
Last Name:ZIMMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14217 WATERFOWL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1644
Mailing Address - Country:US
Mailing Address - Phone:919-309-5060
Mailing Address - Fax:
Practice Address - Street 1:3000 LATROBE DR STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5227
Practice Address - Country:US
Practice Address - Phone:704-612-6537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician