Provider Demographics
NPI:1376570150
Name:LONG, SUSAN KAY (ATC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KAY
Last Name:LONG
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1627 POEPPEL RD
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-9329
Mailing Address - Country:US
Mailing Address - Phone:920-563-0914
Mailing Address - Fax:
Practice Address - Street 1:621 SCIENCE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1074
Practice Address - Country:US
Practice Address - Phone:608-262-1292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI390-286-215OtherTAX ID NUMBER