Provider Demographics
NPI:1265295307
Name:LONGSWORTH PHYSICAL THERAPY AND WELLNESS
Entity type:Organization
Organization Name:LONGSWORTH PHYSICAL THERAPY AND WELLNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA SHARMAINE
Authorized Official - Middle Name:TING
Authorized Official - Last Name:LONGSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:773-707-8910
Mailing Address - Street 1:7212 W GREENLEAF ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-2116
Mailing Address - Country:US
Mailing Address - Phone:773-707-8910
Mailing Address - Fax:
Practice Address - Street 1:1100 N BLUE MOUND RD STE 130
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:TX
Practice Address - Zip Code:76131-4902
Practice Address - Country:US
Practice Address - Phone:773-707-8910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty