Healthcare Provider Details

I. General information

NPI: 1659209047
Provider Name (Legal Business Name): THE LIFELONG ATHLETE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 FREEDOM WAY
MERRIMAC MA
01860-2141
US

IV. Provider business mailing address

26 FREEDOM WAY
MERRIMAC MA
01860-2141
US

V. Phone/Fax

Practice location:
  • Phone: 978-604-4113
  • Fax:
Mailing address:
  • Phone: 978-604-4113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAUREN BENNETT
Title or Position: OWNER, PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 978-604-4113