Provider Demographics
NPI:1235645573
Name:LONG, WANITA L (PTA)
Entity Type:Individual
Prefix:
First Name:WANITA
Middle Name:L
Last Name:LONG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 GARRISTON RD
Mailing Address - Street 2:
Mailing Address - City:YORK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17370-9519
Mailing Address - Country:US
Mailing Address - Phone:717-418-2359
Mailing Address - Fax:
Practice Address - Street 1:100 MOUNT ALLEN DR
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17055-6171
Practice Address - Country:US
Practice Address - Phone:717-697-4666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE1002876225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant