Provider Demographics
NPI:1902218126
Name:LONG, MARY BETH
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:BETH
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 LINCOLN ST SW
Mailing Address - Street 2:
Mailing Address - City:HARTVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44632-9382
Mailing Address - Country:US
Mailing Address - Phone:330-877-4276
Mailing Address - Fax:330-877-4738
Practice Address - Street 1:225 LINCOLN ST SW
Practice Address - Street 2:
Practice Address - City:HARTVILLE
Practice Address - State:OH
Practice Address - Zip Code:44632-9382
Practice Address - Country:US
Practice Address - Phone:330-877-4276
Practice Address - Fax:330-877-4738
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-6563235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSP-6563Medicaid