Healthcare Provider Details

I. General information

NPI: 1982363156
Provider Name (Legal Business Name): ZAKARY G SHROCK LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1346 STRAWBERRY DR SW
BANDON OR
97411-8814
US

IV. Provider business mailing address

1346 STRAWBERRY DR SW
BANDON OR
97411-8814
US

V. Phone/Fax

Practice location:
  • Phone: 765-481-9080
  • Fax:
Mailing address:
  • Phone: 765-481-9080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC10093
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6592
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: