Provider Demographics
NPI:1164548343
Name:LONG, STEPHANIE LYN (OTR)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYN
Last Name:LONG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5742 E ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46158-6307
Mailing Address - Country:US
Mailing Address - Phone:317-414-8467
Mailing Address - Fax:317-831-7679
Practice Address - Street 1:5742 E ORCHARD RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-6307
Practice Address - Country:US
Practice Address - Phone:317-414-8467
Practice Address - Fax:317-831-7679
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004068A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist