Basic Information
| Provider Information | |||||||||
| NPI: | 1194244277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | GRAY | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1195 HISEY AVE | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226642097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404597772 | ||||||||
| FaxNumber: | 5404597782 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 NEW FIDELITY CT | ||||||||
| Address2: | |||||||||
| City: | GARNER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275292665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192582714 | ||||||||
| FaxNumber: | 4106484878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2017 | ||||||||
| LastUpdateDate: | 11/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 2305211480 | VA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 2305211480 | 01 | VA | COMMONWEALTH OF VIRGINIA BOARD OF PHYSICAL THERAPY LICENSE | OTHER |