Healthcare Provider Details

I. General information

NPI: 1194747022
Provider Name (Legal Business Name): STANLEY A. ZUCKERMAN MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 W HAYS STREET
BOISE ID
83702-5028
US

IV. Provider business mailing address

1408 W HAYS STREET
BOISE ID
83702-5028
US

V. Phone/Fax

Practice location:
  • Phone: 208-385-9200
  • Fax: 208-336-7125
Mailing address:
  • Phone: 208-385-9200
  • Fax: 208-336-7125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW1219
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: