Provider Demographics
NPI:1124600986
Name:LONGBOTTOM, SETH THOMAS (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:THOMAS
Last Name:LONGBOTTOM
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 CHARLOIS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1521
Mailing Address - Country:US
Mailing Address - Phone:336-725-0222
Mailing Address - Fax:
Practice Address - Street 1:185 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1521
Practice Address - Country:US
Practice Address - Phone:336-725-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15310235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist