Provider Demographics
NPI:1659649499
Name:SHOUP, ZACHARY DAVID (LSW)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:DAVID
Last Name:SHOUP
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13555 NEAPOLIS WATERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:OH
Mailing Address - Zip Code:43522-9649
Mailing Address - Country:US
Mailing Address - Phone:419-575-5992
Mailing Address - Fax:
Practice Address - Street 1:600 FREEDOM DR
Practice Address - Street 2:
Practice Address - City:NAPOLEON
Practice Address - State:OH
Practice Address - Zip Code:43545-9038
Practice Address - Country:US
Practice Address - Phone:419-599-1660
Practice Address - Fax:419-592-8336
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1101529104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker