Provider Demographics
NPI:1114384245
Name:LONG, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5530 WESTBURY DR
Mailing Address - Street 2:
Mailing Address - City:ENOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17025-3316
Mailing Address - Country:US
Mailing Address - Phone:240-416-1727
Mailing Address - Fax:
Practice Address - Street 1:5530 WESTBURY DR
Practice Address - Street 2:
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-3316
Practice Address - Country:US
Practice Address - Phone:240-416-1727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL012829235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist