1083157085 NPI number — ZACHARY CHARLES TALBOTT MSW, LMSW, LADAC, MAC, CAADC, CCS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083157085 NPI number — ZACHARY CHARLES TALBOTT MSW, LMSW, LADAC, MAC, CAADC, CCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TALBOTT
Provider First Name:
ZACHARY
Provider Middle Name:
CHARLES
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LMSW, LADAC, MAC, CAADC, CCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083157085
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1821 W Broadway Ave
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
Maryville
Provider Business Mailing Address State Name:
Tennessee
Provider Business Mailing Address Postal Code:
37801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
8657240852
Provider Business Mailing Address Fax Number:
8657240853

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1821 W Broadway Ave
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
Maryville
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
8657240852
Provider Business Practice Location Address Fax Number:
8657240853
Provider Enumeration Date:
11/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1413 , registered in the state of Tennessee ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: License #1413 . This is a "Tennessee Board of Alcohol and Drug Abuse Counselors" identifier , issued by the state of ( Tennessee ) . This identifiers is of the category "Qualified Clinical Supervisor (QCS)".
  • Identifier: Certification #140 . This is a "Alcohol and Drug Abuse Certification Board of Georgia" identifier , issued by the state of ( Georgia ) . This identifiers is of the category "Certified Clinical Supervisor (CCS)".
  • Identifier: Certification #512290 . This is a "National Certification Commission for Addiction Professionals" identifier , issued by the state of ( n/a ) . This identifiers is of the category "Master Addiction Counselor (MAC)".




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