Provider Demographics
NPI:1184992596
Name:GRISHAM, ZACHARY BROCK
Entity type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:BROCK
Last Name:GRISHAM
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 1:17330 PRESTON ROAD STE 110B
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252
Mailing Address - Country:US
Mailing Address - Phone:214-396-6526
Mailing Address - Fax:972-250-1701
Practice Address - Street 1:17330 PRESTON ROAD STE 110B
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252
Practice Address - Country:US
Practice Address - Phone:214-396-6526
Practice Address - Fax:972-250-1701
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68651101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional