Provider Demographics
NPI:1891277109
Name:LONG, LAURA SUSAN (SLP)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:SUSAN
Last Name:LONG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-8075
Mailing Address - Country:US
Mailing Address - Phone:270-339-2183
Mailing Address - Fax:
Practice Address - Street 1:425 ISLAND FORD RD.
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-4243
Practice Address - Country:US
Practice Address - Phone:270-825-0166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist