Provider Demographics
NPI:1003902875
Name:LONG, TIM (PT)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:TIMOTHY
Other - Middle Name:ALAN
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:430 MORTON PLANT ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3398
Mailing Address - Country:US
Mailing Address - Phone:727-298-5230
Mailing Address - Fax:727-298-5205
Practice Address - Street 1:430 MORTON PLANT ST
Practice Address - Street 2:SUITE 206
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3398
Practice Address - Country:US
Practice Address - Phone:727-298-5230
Practice Address - Fax:727-298-5205
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT6384225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist