Healthcare Provider Details

I. General information

NPI: 1255468708
Provider Name (Legal Business Name): CHARLES PHILLIP ZACHARY JR. BS LBSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43740 N GROESBECK HWY
CLINTON TOWNSHIP MI
48036-1139
US

IV. Provider business mailing address

40134 WINSLOW CT
STERLING HEIGHTS MI
48310-2071
US

V. Phone/Fax

Practice location:
  • Phone: 586-469-7817
  • Fax: 586-469-7662
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802065743
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: