Provider Demographics
NPI:1053597344
Name:WARREN, ZAKERY R (LCPC4472)
Entity type:Individual
Prefix:MR
First Name:ZAKERY
Middle Name:R
Last Name:WARREN
Suffix:
Gender:M
Credentials:LCPC4472
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-6601
Mailing Address - Country:US
Mailing Address - Phone:208-346-7500
Mailing Address - Fax:208-346-7501
Practice Address - Street 1:2705 E 17TH ST STE A
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6601
Practice Address - Country:US
Practice Address - Phone:208-346-7500
Practice Address - Fax:208-346-7501
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4472101YM0800X
IDLPC39601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002648300Medicaid