Healthcare Provider Details

I. General information

NPI: 1174216089
Provider Name (Legal Business Name): ZACHARY TABER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 05/29/2023
Certification Date: 05/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1074 PONCE DE LEON AVE NE
ATLANTA GA
30306-4216
US

IV. Provider business mailing address

554 ELBRIDGE DR NW
ATLANTA GA
30318-8148
US

V. Phone/Fax

Practice location:
  • Phone: 678-369-3235
  • Fax:
Mailing address:
  • Phone: 631-805-6693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License NumberPSY004644
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY004644
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: