Healthcare Provider Details

I. General information

NPI: 1700559804
Provider Name (Legal Business Name): MICHAEL KENT ZAVALA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4070 VICTORIA WAY APT 27
LEXINGTON KY
40515-4661
US

IV. Provider business mailing address

4070 VICTORIA WAY APT 27
LEXINGTON KY
40515-4661
US

V. Phone/Fax

Practice location:
  • Phone: 503-620-1191
  • Fax:
Mailing address:
  • Phone: 971-388-7056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number286535
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR7598
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: