Provider Demographics
NPI:1174861439
Name:LONG, NATALIE (RD)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 BUTLER RD
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-6507
Mailing Address - Country:US
Mailing Address - Phone:409-332-5031
Mailing Address - Fax:
Practice Address - Street 1:1027 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:TX
Practice Address - Zip Code:77657-7362
Practice Address - Country:US
Practice Address - Phone:409-751-0100
Practice Address - Fax:409-751-0700
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-22
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81339133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered