Provider Demographics
NPI:1396333944
Name:LONG, PATRICIA AUGUSTA (MSED, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:AUGUSTA
Last Name:LONG
Suffix:
Gender:F
Credentials:MSED, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 INDEPENDENCE RD
Mailing Address - Street 2:
Mailing Address - City:HURLBURT FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32544-5601
Mailing Address - Country:US
Mailing Address - Phone:914-656-3126
Mailing Address - Fax:
Practice Address - Street 1:1895 BAYOU DR
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-7601
Practice Address - Country:US
Practice Address - Phone:914-656-3126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL37212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer