Healthcare Provider Details

I. General information

NPI: 1023539475
Provider Name (Legal Business Name): CASEY ZACK PHD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21633 AVENUE 24
CHOWCHILLA CA
93610-9650
US

IV. Provider business mailing address

21633 AVENUE 24
CHOWCHILLA CA
93610-9650
US

V. Phone/Fax

Practice location:
  • Phone: 559-665-6100
  • Fax:
Mailing address:
  • Phone: 559-665-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY29850
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY29850
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY29850
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: