Provider Demographics
NPI:1255763439
Name:LONGHURST, JUSTIN DENIS (DPT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DENIS
Last Name:LONGHURST
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-6937
Mailing Address - Country:US
Mailing Address - Phone:207-778-6469
Mailing Address - Fax:207-778-3486
Practice Address - Street 1:4640 S 3500 W
Practice Address - Street 2:SUITE 3
Practice Address - City:WEST HAVEN
Practice Address - State:UT
Practice Address - Zip Code:84401-6521
Practice Address - Country:US
Practice Address - Phone:801-689-0200
Practice Address - Fax:801-689-0201
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4807225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist