Provider Demographics
NPI:1043935877
Name:WOODARD, ZACKARY DOUGLAS
Entity type:Individual
Prefix:
First Name:ZACKARY
Middle Name:DOUGLAS
Last Name:WOODARD
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 1:5769 PETTIS CT NE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8226
Mailing Address - Country:US
Mailing Address - Phone:269-924-6114
Mailing Address - Fax:
Practice Address - Street 1:120 STEVENS ST SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1526
Practice Address - Country:US
Practice Address - Phone:616-469-3870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106E00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst