Provider Demographics
NPI:1619694312
Name:KINNEY, ZACHARY (RECOVERY COACH)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:KINNEY
Suffix:
Gender:M
Credentials:RECOVERY COACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 RAVINE DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4031
Mailing Address - Country:US
Mailing Address - Phone:608-633-2712
Mailing Address - Fax:
Practice Address - Street 1:5230 W MOONLIGHT MINE RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-9013
Practice Address - Country:US
Practice Address - Phone:208-478-0219
Practice Address - Fax:208-944-9655
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13056175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist