Basic Information
| Provider Information | |||||||||
| NPI: | 1578696118 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | ANGIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4206 GREENBRIAR DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797075423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4322621004 | ||||||||
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| Practice Location | |||||||||
| Address1: | 620 N ALLEGHANEY AVE | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797614408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323328244 | ||||||||
| FaxNumber: | 4325807428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225X00000X | 105493 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 105493 | 01 | TX | STATE LICENSE NUMBER | OTHER | 8T4670 | 01 | TX | BCBS PROVIDER NUMBER | OTHER |