Provider Demographics
NPI:1316413917
Name:LONG, MICHAEL DREW (CPSS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DREW
Last Name:LONG
Suffix:
Gender:M
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:996 W 800 S
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-2766
Mailing Address - Country:US
Mailing Address - Phone:801-500-0594
Mailing Address - Fax:801-465-7762
Practice Address - Street 1:996 W 800 S
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-2766
Practice Address - Country:US
Practice Address - Phone:801-500-0594
Practice Address - Fax:801-465-7762
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT706175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist