Provider Demographics
NPI:1093890279
Name:LONG, TARA LEA (PT)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LEA
Last Name:LONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 LONGLEAF CT
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-5767
Mailing Address - Country:US
Mailing Address - Phone:803-641-1869
Mailing Address - Fax:
Practice Address - Street 1:690 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6348
Practice Address - Country:US
Practice Address - Phone:803-648-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4043225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH1327Medicaid