Provider Demographics
NPI:1811780646
Name:LONG, VALIECE TIARA (MS)
Entity type:Individual
Prefix:
First Name:VALIECE
Middle Name:TIARA
Last Name:LONG
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:VALIECE
Other - Middle Name:TIARA
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 2343
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-2343
Mailing Address - Country:US
Mailing Address - Phone:727-590-2303
Mailing Address - Fax:
Practice Address - Street 1:750 CHASTAIN COR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-8518
Practice Address - Country:US
Practice Address - Phone:727-590-2303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-24
Last Update Date:2025-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19340000X207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty