Provider Demographics
NPI:1396778296
Name:LONGO, THEA FLUEVOG (PT)
Entity type:Individual
Prefix:
First Name:THEA
Middle Name:FLUEVOG
Last Name:LONGO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6803 TROPICAIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286-4444
Mailing Address - Country:US
Mailing Address - Phone:941-240-5425
Mailing Address - Fax:
Practice Address - Street 1:333 TAMIAMI TRL S
Practice Address - Street 2:SUITE 207
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2402
Practice Address - Country:US
Practice Address - Phone:941-484-5659
Practice Address - Fax:941-484-5487
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT2561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist