Provider Demographics
NPI:1306318647
Name:DELONG, JUSTIN GREGORY
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:GREGORY
Last Name:DELONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 ROOFTOP CT
Mailing Address - Street 2:
Mailing Address - City:STEPHENSON
Mailing Address - State:VA
Mailing Address - Zip Code:22656-1983
Mailing Address - Country:US
Mailing Address - Phone:916-743-4346
Mailing Address - Fax:
Practice Address - Street 1:1 HEALTHY WAY
Practice Address - Street 2:
Practice Address - City:BERKELEY SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:25411-7463
Practice Address - Country:US
Practice Address - Phone:304-258-6516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212262225100000X
WVPT003716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist