Healthcare Provider Details

I. General information

NPI: 1710822440
Provider Name (Legal Business Name): LETICIA LONGORIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LETI LONGORIA

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 FOREST HILL AVE SE
GRAND RAPIDS MI
49546-3626
US

IV. Provider business mailing address

5349 MARTIN RD
NORTON SHORES MI
49441-5602
US

V. Phone/Fax

Practice location:
  • Phone: 616-726-8595
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502000900
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: