Provider Demographics
NPI:1386217172
Name:LONGO, SAMUEL JAMES (PT, DPT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JAMES
Last Name:LONGO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3607 RAFTERSRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-3747
Mailing Address - Country:US
Mailing Address - Phone:516-459-9288
Mailing Address - Fax:
Practice Address - Street 1:3607 RAFTERSRIDGE DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-3747
Practice Address - Country:US
Practice Address - Phone:516-459-9288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305213946208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305213946OtherPHYSICAL THERAPY LICENSE