Provider Demographics
NPI:1083758593
Name:LONG, STACY MARIE (ATC)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3208 CHURCHILL AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48506-3021
Mailing Address - Country:US
Mailing Address - Phone:810-736-3954
Mailing Address - Fax:
Practice Address - Street 1:G-3100 VAN SLYKE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48551-0001
Practice Address - Country:US
Practice Address - Phone:810-835-0068
Practice Address - Fax:810-835-0069
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer