Healthcare Provider Details

I. General information

NPI: 1609375807
Provider Name (Legal Business Name): ZACHARY TAYLOR ROBERTSON PT, DPT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2018
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 JESSE JEWELL PKWY NE
GAINESVILLE GA
30501-2561
US

IV. Provider business mailing address

2400 WISTERIA DR STE A
SNELLVILLE GA
30078-2689
US

V. Phone/Fax

Practice location:
  • Phone: 770-536-9300
  • Fax: 770-536-9389
Mailing address:
  • Phone: 770-982-0102
  • Fax: 770-982-0130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT015257
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: