Healthcare Provider Details

I. General information

NPI: 1366012148
Provider Name (Legal Business Name): ZACHARY RYAN KUSTER M.DIV., M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 06/07/2026
Certification Date: 06/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12135 PANAMA CITY BEACH PKWY
PANAMA CITY BEACH FL
32407-2609
US

IV. Provider business mailing address

12135 PANAMA CITY BEACH PKWY
PANAMA CITY BEACH FL
32407-2609
US

V. Phone/Fax

Practice location:
  • Phone: 850-270-8341
  • Fax:
Mailing address:
  • Phone: 850-270-8341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number22504
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: