Provider Demographics
NPI:1104311521
Name:LONG, STEPHANIE LAUREN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LAUREN
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 THOMPSON SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-5974
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 PARK AVE
Practice Address - Street 2:
Practice Address - City:ADAMSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38310-2461
Practice Address - Country:US
Practice Address - Phone:731-632-3301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist