Provider Demographics
NPI:1770976615
Name:WYMAN, ZACHARY
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:WYMAN
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 1:1362 E LUGONIA AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2713
Mailing Address - Country:US
Mailing Address - Phone:530-614-0066
Mailing Address - Fax:909-252-4055
Practice Address - Street 1:1362 E LUGONIA AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2713
Practice Address - Country:US
Practice Address - Phone:530-614-0066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-16-22983103K00000X
390200000X
CA94603106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-16-22983OtherBCBA CERTIFICATION
94603OtherASSOCIATE MARRIAGE AND FAMILY THERAPY