Provider Demographics
NPI:1346476629
Name:LONG, GLORIA K (MACCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:K
Last Name:LONG
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 S 400 E
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-9358
Mailing Address - Country:US
Mailing Address - Phone:765-455-0206
Mailing Address - Fax:
Practice Address - Street 1:3321 S 400 E
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-9358
Practice Address - Country:US
Practice Address - Phone:765-455-0206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22001228235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist