Healthcare Provider Details

I. General information

NPI: 1164523007
Provider Name (Legal Business Name): CRISTOBAL ZAMORA L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10045 W LISBON AVE SUITE 200
WAUWATOSA WI
53222-2446
US

IV. Provider business mailing address

10045 W LISBON AVE SUITE 200
WAUWATOSA WI
53222-2446
US

V. Phone/Fax

Practice location:
  • Phone: 414-358-7144
  • Fax: 414-358-7158
Mailing address:
  • Phone: 414-358-7144
  • Fax: 414-358-7158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7185-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: