Provider Demographics
NPI:1659865996
Name:BERWALDT, ZACHARY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:BERWALDT
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 1:83 CLEAR SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-4153
Mailing Address - Country:US
Mailing Address - Phone:386-793-2476
Mailing Address - Fax:
Practice Address - Street 1:1563 KINGSLEY AVE STE 103
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4503
Practice Address - Country:US
Practice Address - Phone:904-602-9740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-50468106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician