Provider Demographics
NPI:1124471453
Name:LONG, MEGAN (MS)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 TANGLEWOOD DR APT 106
Mailing Address - Street 2:
Mailing Address - City:DEFOREST
Mailing Address - State:WI
Mailing Address - Zip Code:53532-1795
Mailing Address - Country:US
Mailing Address - Phone:715-323-6697
Mailing Address - Fax:
Practice Address - Street 1:300 RACE ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-1822
Practice Address - Country:US
Practice Address - Phone:608-254-2574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4330154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist