Provider Demographics
NPI:1962027144
Name:ALLEN, ZACHARY TYLER
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:TYLER
Last Name:ALLEN
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 1:9019 WASHINGTON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2435
Mailing Address - Country:US
Mailing Address - Phone:505-856-6880
Mailing Address - Fax:
Practice Address - Street 1:9019 WASHINGTON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2435
Practice Address - Country:US
Practice Address - Phone:505-856-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician