Healthcare Provider Details

I. General information

NPI: 1851503049
Provider Name (Legal Business Name): SPENCER TODD ZITZMAN PHD, LMFT-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 JOHN ADAMS PKWY SUITE 102
IDAHO FALLS ID
83401-4300
US

IV. Provider business mailing address

1600 JOHN ADAMS PKWY SUITE 102
IDAHO FALLS ID
83401-4300
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-5276
  • Fax: 208-529-6506
Mailing address:
  • Phone: 208-529-5276
  • Fax: 208-529-6506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberF0600002
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT-4766
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: