Provider Demographics
NPI:1194076570
Name:LONG, CECELIA A (OT)
Entity type:Individual
Prefix:
First Name:CECELIA
Middle Name:A
Last Name:LONG
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 STATE ST
Mailing Address - Street 2:#5
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4968
Mailing Address - Country:US
Mailing Address - Phone:217-224-1750
Mailing Address - Fax:217-224-0403
Practice Address - Street 1:804 STATE ST
Practice Address - Street 2:#5
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4968
Practice Address - Country:US
Practice Address - Phone:217-224-1750
Practice Address - Fax:217-224-0403
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056009853225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist