Provider Demographics
NPI:1649885310
Name:LONGO, ANTHONY WILLIAM (LMT)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:WILLIAM
Last Name:LONGO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4213
Mailing Address - Country:US
Mailing Address - Phone:415-855-5699
Mailing Address - Fax:
Practice Address - Street 1:801 7TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4213
Practice Address - Country:US
Practice Address - Phone:415-855-5699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71075225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist