Provider Demographics
NPI:1700982899
Name:ZACK, WENDY JOAN (PHD)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:JOAN
Last Name:ZACK
Suffix:
Gender:F
Credentials:PHD
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 631856
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21263-1856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4440 WILLARD AVE APT 317
Practice Address - Street 2:
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-3745
Practice Address - Country:US
Practice Address - Phone:202-213-9533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC3018731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R97363Medicare UPIN
DC019129M64Medicare ID - Type Unspecified