Provider Demographics
NPI:1821660994
Name:VANLEEUWEN, ZACHARY TAFT
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:TAFT
Last Name:VANLEEUWEN
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 1:115 GOLF COURSE RD STE E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321
Mailing Address - Country:US
Mailing Address - Phone:435-799-5035
Mailing Address - Fax:
Practice Address - Street 1:115 GOLF COURSE RD STE E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321
Practice Address - Country:US
Practice Address - Phone:435-799-5035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12086457-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist