Provider Demographics
NPI:1861599912
Name:HALE, ZACKARY M (AUD)
Entity type:Individual
Prefix:PROF
First Name:ZACKARY
Middle Name:M
Last Name:HALE
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3345 MERLIN DR
Mailing Address - Street 2:STE 200
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7405
Mailing Address - Country:US
Mailing Address - Phone:208-529-1514
Mailing Address - Fax:208-529-3170
Practice Address - Street 1:3345 MERLIN DR
Practice Address - Street 2:STE 200
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7405
Practice Address - Country:US
Practice Address - Phone:208-529-1514
Practice Address - Fax:208-529-3170
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYA-998231H00000X
IDAUD-1128231HA2500X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807077000Medicaid
ID1580453Medicare ID - Type UnspecifiedLEGACY #