Provider Demographics
NPI:1356663991
Name:LONG, MICHELLE BLACKWELL (PT)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:BLACKWELL
Last Name:LONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:BLACKWELL
Other - Last Name:CARDOSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4406 S FLORIDA AVE
Mailing Address - Street 2:SUITE #16
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2172
Mailing Address - Country:US
Mailing Address - Phone:863-688-1800
Mailing Address - Fax:863-688-1824
Practice Address - Street 1:4406 S FLORIDA AVE
Practice Address - Street 2:SUITE #16
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2172
Practice Address - Country:US
Practice Address - Phone:863-688-1800
Practice Address - Fax:863-688-1824
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0025201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist