Provider Demographics
NPI:1609375807
Name:ROBERTSON, ZACHARY TAYLOR (PT, DPT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:TAYLOR
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PT, DPT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 WISTERIA DR STE A
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2689
Mailing Address - Country:US
Mailing Address - Phone:770-982-0102
Mailing Address - Fax:770-982-0130
Practice Address - Street 1:1640 JESSE JEWELL PKWY NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2561
Practice Address - Country:US
Practice Address - Phone:770-536-9300
Practice Address - Fax:770-536-9389
Is Sole Proprietor?:No
Enumeration Date:2018-02-03
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
GAPT015257225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer