=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013456839
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ZACHARY BURNS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2017
-----------------------------------------------------
Last Update Date | 02/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8 MORGAN BLVD
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46383-4836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-916-2521
-----------------------------------------------------
Fax | 219-462-4741
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 E 150 S
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46383-9606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-916-2521
-----------------------------------------------------
Fax | 219-462-4741
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT / CLINICAL DIRECTOR
-----------------------------------------------------
Name | MR. ZACHARY EDWARD BURNS
-----------------------------------------------------
Credential | M.A. L.C.S.W
-----------------------------------------------------
Telephone | 219-916-2521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 34007410A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------