Provider Demographics
NPI:1043646409
Name:LONG, SCOTT T (ATC,LAT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:T
Last Name:LONG
Suffix:
Gender:M
Credentials:ATC,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5158
Mailing Address - Country:US
Mailing Address - Phone:575-655-6500
Mailing Address - Fax:575-622-9777
Practice Address - Street 1:113 E COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5158
Practice Address - Country:US
Practice Address - Phone:575-655-6500
Practice Address - Fax:575-622-9777
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer