Provider Demographics
NPI:1457739112
Name:ZACK, SAMUEL ALAN (LCPC)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ALAN
Last Name:ZACK
Suffix:
Gender:
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20851-1455
Mailing Address - Country:US
Mailing Address - Phone:240-271-3594
Mailing Address - Fax:
Practice Address - Street 1:1609 MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20851-1455
Practice Address - Country:US
Practice Address - Phone:240-271-3594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC11329101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional