Provider Demographics
NPI:1053304840
Name:LONG, THOMAS J (PT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:J
Last Name:LONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 W PEORIA AVE
Mailing Address - Street 2:SUITE D800
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-4608
Mailing Address - Country:US
Mailing Address - Phone:602-866-2231
Mailing Address - Fax:602-866-2261
Practice Address - Street 1:3201 W PEORIA AVE
Practice Address - Street 2:SUITE D800
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4608
Practice Address - Country:US
Practice Address - Phone:602-866-2231
Practice Address - Fax:602-866-2261
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5239225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0460200OtherBCBS
AZ007171346OtherAETNA
AZ511198Medicaid
AZ511198Medicaid