Provider Demographics
NPI:1134790512
Name:MARTIN, ZACHARY WILLIAM
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:WILLIAM
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4510 ENCHANTED DR
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-9300
Mailing Address - Country:US
Mailing Address - Phone:952-686-4108
Mailing Address - Fax:
Practice Address - Street 1:7661 W RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-6186
Practice Address - Country:US
Practice Address - Phone:208-912-6986
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst