Basic Information
Provider Information | |||||||||
NPI: | 1316368152 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LONG | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LONG | ||||||||
OtherFirstName: | KATHERINE | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.A. CCC-SLP | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3905 BRAESGATE LN | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336241806 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8135251323 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4443 ROWAN RD | ||||||||
Address2: |   | ||||||||
City: | NEW PORT RICHEY | ||||||||
State: | FL | ||||||||
PostalCode: | 346536198 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7278469900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2013 | ||||||||
LastUpdateDate: | 09/07/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA12208 | FL | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.