Healthcare Provider Details

I. General information

NPI: 1639642119
Provider Name (Legal Business Name): BRENNA LONGO MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

17411 WINSLOW RD
SHAKER HEIGHTS OH
44120-3425
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-2200
  • Fax:
Mailing address:
  • Phone: 412-552-0484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAT004534
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: