Provider Demographics
NPI:1215610886
Name:LONG, HARRIETT GAYLE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:HARRIETT
Middle Name:GAYLE
Last Name:LONG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3611 AMBROSIA LN
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3054
Mailing Address - Country:US
Mailing Address - Phone:417-669-6598
Mailing Address - Fax:
Practice Address - Street 1:2713 SE I ST STE 5
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-0078
Practice Address - Country:US
Practice Address - Phone:479-250-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023027329235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist