Provider Demographics
NPI:1093802381
Name:LONG, JOEL M (MPT, OCS)
Entity Type:Individual
Prefix:MR
First Name:JOEL
Middle Name:M
Last Name:LONG
Suffix:
Gender:M
Credentials:MPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5414 S IVORY ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-6333
Mailing Address - Country:US
Mailing Address - Phone:509-448-0264
Mailing Address - Fax:
Practice Address - Street 1:407 E 2ND AVE STE 100
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1428
Practice Address - Country:US
Practice Address - Phone:509-455-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
S44437Medicare UPIN