Provider Demographics
NPI:1780052506
Name:JOHNSON, ZACHARY C
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:C
Last Name:JOHNSON
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 1:5708 75TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3635
Mailing Address - Country:US
Mailing Address - Phone:262-697-9135
Mailing Address - Fax:262-697-9175
Practice Address - Street 1:5708 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3635
Practice Address - Country:US
Practice Address - Phone:262-697-9135
Practice Address - Fax:262-697-9175
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13254-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist