Provider Demographics
NPI:1669169918
Name:LONGSTREET, RICHARD
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:LONGSTREET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7369 BONITA VISTA WAY APT 202
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-8697
Mailing Address - Country:US
Mailing Address - Phone:813-765-4080
Mailing Address - Fax:
Practice Address - Street 1:7369 BONITA VISTA WAY APT 202
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-8697
Practice Address - Country:US
Practice Address - Phone:813-765-4080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities