Provider Demographics
NPI:1336964469
Name:LONG, BRODIE ROBERT (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:BRODIE
Middle Name:ROBERT
Last Name:LONG
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 SAXON WAY APT D
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6536
Mailing Address - Country:US
Mailing Address - Phone:406-439-3676
Mailing Address - Fax:
Practice Address - Street 1:301 EDELWEISS DR STE 7
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-3931
Practice Address - Country:US
Practice Address - Phone:406-219-2114
Practice Address - Fax:406-219-2145
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-22
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT224Z00000X, 235Z00000X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics