Healthcare Provider Details

I. General information

NPI: 1659649499
Provider Name (Legal Business Name): ZACHARY DAVID SHOUP LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 FREEDOM DR
NAPOLEON OH
43545-9038
US

IV. Provider business mailing address

13555 NEAPOLIS WATERVILLE RD
GRAND RAPIDS OH
43522-9649
US

V. Phone/Fax

Practice location:
  • Phone: 419-599-1660
  • Fax: 419-592-8336
Mailing address:
  • Phone: 419-575-5992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1101529
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: