Healthcare Provider Details

I. General information

NPI: 1225877384
Provider Name (Legal Business Name): BREANNA MARIE ZOLD MAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 W BANNOCK ST STE 1100
BOISE ID
83702-6140
US

IV. Provider business mailing address

950 W BANNOCK ST STE 1100
BOISE ID
83702-6140
US

V. Phone/Fax

Practice location:
  • Phone: 323-205-7088
  • Fax:
Mailing address:
  • Phone: 323-205-7088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9881601
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number138166
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12167125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: