Provider Demographics
NPI:1528524352
Name:SOMATIC PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:SOMATIC PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CMTPT
Authorized Official - Phone:920-940-8350
Mailing Address - Street 1:1576 FOLKSTONE RD NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-1305
Mailing Address - Country:US
Mailing Address - Phone:920-940-8350
Mailing Address - Fax:404-393-4680
Practice Address - Street 1:210 SOUTH ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3738
Practice Address - Country:US
Practice Address - Phone:470-215-0862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT009781OtherPT LICENSE NUMBER
GA18158OtherDRY NEEDLING CERTIFICATION, MYOPAIN 6-10-18