Healthcare Provider Details

I. General information

NPI: 1073163788
Provider Name (Legal Business Name): BREANNA LONGENETTE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BREANNA BANE

II. Dates (important events)

Enumeration Date: 09/14/2019
Last Update Date: 09/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5833 W I 20
ARLINGTON TX
76017-1057
US

IV. Provider business mailing address

9629 OLIVIA DR
FORT WORTH TX
76108-3877
US

V. Phone/Fax

Practice location:
  • Phone: 817-516-1115
  • Fax: 817-516-1104
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1321249
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: