Healthcare Provider Details

I. General information

NPI: 1043134620
Provider Name (Legal Business Name): ZACHARY HEATON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 W CENTER ST STE 3
POCATELLO ID
83204-3236
US

IV. Provider business mailing address

707 N ARTHUR AVE
POCATELLO ID
83204-2901
US

V. Phone/Fax

Practice location:
  • Phone: 208-244-0081
  • Fax: 833-307-2598
Mailing address:
  • Phone: 360-721-0091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number5381021
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: