Provider Demographics
NPI:1992544951
Name:ZACK, ALISSA MAE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ALISSA
Middle Name:MAE
Last Name:ZACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4474 W CALVARY RD
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55803-1269
Mailing Address - Country:US
Mailing Address - Phone:218-591-8590
Mailing Address - Fax:
Practice Address - Street 1:4474 W CALVARY RD
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55803-1269
Practice Address - Country:US
Practice Address - Phone:218-591-8590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN315211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical