Provider Demographics
NPI:1003525957
Name:LONG, ANTOINETTE (LMT)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 N PARK RD APT C301
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1354
Mailing Address - Country:US
Mailing Address - Phone:610-781-8806
Mailing Address - Fax:
Practice Address - Street 1:855 N PARK RD APT C301
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1354
Practice Address - Country:US
Practice Address - Phone:610-781-8806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG013531225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist