Provider Demographics
NPI:1386070688
Name:LONG, SUSANA (MSED)
Entity type:Individual
Prefix:MS
First Name:SUSANA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-5009
Mailing Address - Country:US
Mailing Address - Phone:516-724-6869
Mailing Address - Fax:
Practice Address - Street 1:44 4TH AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-5009
Practice Address - Country:US
Practice Address - Phone:516-724-6869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY779621131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist