Provider Demographics
NPI:1073013124
Name:LONG, CAROLYN ANN (SLP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 TERRACE GARDEN DR APT 1
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078-1126
Mailing Address - Country:US
Mailing Address - Phone:276-629-5084
Mailing Address - Fax:
Practice Address - Street 1:740 FIGSBORO RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-6770
Practice Address - Country:US
Practice Address - Phone:276-634-0103
Practice Address - Fax:276-634-0227
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2203000347235Z00000X
VA2202004067235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist