Provider Demographics
NPI:1396770152
Name:ZOOK, LEE J (PHD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:J
Last Name:ZOOK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 S VINE ST
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:IA
Mailing Address - Zip Code:52175-1354
Mailing Address - Country:US
Mailing Address - Phone:319-422-6267
Mailing Address - Fax:563-927-7409
Practice Address - Street 1:709 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1526
Practice Address - Country:US
Practice Address - Phone:563-927-7330
Practice Address - Fax:563-927-7409
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0091637Medicaid
IA09971OtherBCIA
IAI16181Medicare ID - Type Unspecified
IA0091637Medicaid