Provider Demographics
NPI:1073631032
Name:LONG, THERESA D (MPT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:D
Last Name:LONG
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
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Mailing Address - Street 1:7419 E 131ST ST S
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-3113
Mailing Address - Country:US
Mailing Address - Phone:918-369-3179
Mailing Address - Fax:918-369-3179
Practice Address - Street 1:4815 S HARVARD AVE STE 455
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3078
Practice Address - Country:US
Practice Address - Phone:918-712-7805
Practice Address - Fax:918-712-7813
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK3890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist