Provider Demographics
NPI:1003047838
Name:LONG, MARY LUCILLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LUCILLE
Last Name:LONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LUCILLE
Other - Last Name:ROOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5401 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-2150
Mailing Address - Country:US
Mailing Address - Phone:402-489-7102
Mailing Address - Fax:402-486-9098
Practice Address - Street 1:5401 SOUTH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-2150
Practice Address - Country:US
Practice Address - Phone:402-489-7102
Practice Address - Fax:402-486-9098
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE995225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist