Provider Demographics
NPI:1518380237
Name:LONGSTREET, BENJAMIN P (MA-CCC/SLP)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:P
Last Name:LONGSTREET
Suffix:
Gender:M
Credentials:MA-CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5348 LEEWARD LN
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-3056
Mailing Address - Country:US
Mailing Address - Phone:804-543-6735
Mailing Address - Fax:
Practice Address - Street 1:20 VILLAGE CIR
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-2040
Practice Address - Country:US
Practice Address - Phone:319-524-5772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002420235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist