Provider Demographics
NPI:1346572534
Name:LONG, MATT
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 35TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-1853
Mailing Address - Country:US
Mailing Address - Phone:813-508-3627
Mailing Address - Fax:
Practice Address - Street 1:1120 35TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-1853
Practice Address - Country:US
Practice Address - Phone:813-508-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21300225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant