Provider Demographics
NPI:1740212463
Name:ZYLSTRA, ROBERT G (LCSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:ZYLSTRA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11023
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2023
Mailing Address - Country:US
Mailing Address - Phone:423-778-5445
Mailing Address - Fax:423-778-3157
Practice Address - Street 1:1100 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2201
Practice Address - Country:US
Practice Address - Phone:423-778-8837
Practice Address - Fax:423-778-9301
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3699484Medicare ID - Type Unspecified