Provider Demographics
NPI:1134663941
Name:LONG, RODNEY
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:LEAKESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39451-6530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 MELODY LN
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451-6530
Practice Address - Country:US
Practice Address - Phone:601-394-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2476235Z00000X
PASL011342235Z00000X
WI3843-154235Z00000X
GASLP008471235Z00000X
AL3444235Z00000X
NC10449235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASL011342OtherPA SPEECH THERAPY LICENSE
NC10449OtherNORTH CAROLINA SPEECH THERAPY LICENSE
AL3444OtherAL SPEECH THERAPY LICENSE
GASLP008471OtherGEORGIA SPEECH THERAPY LICENSE
WI3843-154OtherWI SPEECH THERAPY LICENSE
MSS2476OtherMS SPEECH THERAPY LICENSE