Provider Demographics
NPI:1073163788
Name:LONGENETTE, BREANNA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:LONGENETTE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:
Other - Last Name:BANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9629 OLIVIA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-3877
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5833 W I 20
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-1057
Practice Address - Country:US
Practice Address - Phone:817-516-1115
Practice Address - Fax:817-516-1104
Is Sole Proprietor?:No
Enumeration Date:2019-09-14
Last Update Date:2019-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1321249225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist