Provider Demographics
NPI:1851758700
Name:ERISMAN, ZACHARY RYAN
Entity type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:RYAN
Last Name:ERISMAN
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 1:1925 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-8894
Mailing Address - Country:US
Mailing Address - Phone:417-818-1302
Mailing Address - Fax:
Practice Address - Street 1:1925 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-8894
Practice Address - Country:US
Practice Address - Phone:417-818-1302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-23
Last Update Date:2016-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013045299101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional