MEDICARE: KRISTEN LONGEWAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1750016622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN LONGEWAY

Provider Business Mailing Address
First Line	:	4901 WINTHROP AVE W
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-8241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3909 WILKIE WAY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-2859
Country	:	US
Telephone Number	:	817-814-8226
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2022
Last Update Date	:	07/23/2022

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Directions to “ KRISTEN LONGEWAY ” Practice Location

Language	Start Address	Practice Location

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