Provider Demographics
NPI:1013551894
Name:LONG, KELLY DENISE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DENISE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6410 DIAMOND ROCK DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-4241
Mailing Address - Country:US
Mailing Address - Phone:832-867-8739
Mailing Address - Fax:
Practice Address - Street 1:6410 DIAMOND ROCK DR
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-4241
Practice Address - Country:US
Practice Address - Phone:832-867-8739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
TX1325574225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist