Provider Demographics
NPI:1134456569
Name:LONG, EMILY SIMONE' (MED CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:SIMONE'
Last Name:LONG
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:MISS
Other - First Name:EMILY
Other - Middle Name:SIMONE'
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED CCC-SLP
Mailing Address - Street 1:30 OAK RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-8810
Mailing Address - Country:US
Mailing Address - Phone:770-653-2746
Mailing Address - Fax:
Practice Address - Street 1:30 OAK RIDGE CIR
Practice Address - Street 2:
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-8810
Practice Address - Country:US
Practice Address - Phone:770-653-2746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007193235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist