Provider Demographics
NPI:1407956329
Name:LONGO, BRETT J (RPT)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:J
Last Name:LONGO
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27075 SUNNINGDALE WAY
Mailing Address - Street 2:
Mailing Address - City:VALLEY CENTER
Mailing Address - State:CA
Mailing Address - Zip Code:92082-6642
Mailing Address - Country:US
Mailing Address - Phone:760-297-4674
Mailing Address - Fax:760-749-2556
Practice Address - Street 1:27075 SUNNINGDALE WAY
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082-6642
Practice Address - Country:US
Practice Address - Phone:760-297-4674
Practice Address - Fax:760-749-2556
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20230225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY32823Medicare UPIN
CAEO625ZMedicare PIN