Provider Demographics
NPI:1104120914
Name:JOHNSON, ZACHARY (MSPT, MBA)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MSPT, MBA
Other - Prefix:
Other - First Name:ZACK
Other - Middle Name:BLAKE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSPT, MBA
Mailing Address - Street 1:7644 DAWN DR
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80125-8936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 34
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:CO
Practice Address - Zip Code:81639
Practice Address - Country:US
Practice Address - Phone:337-296-0998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-08
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9128225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist