Provider Demographics
NPI:1407628175
Name:LONG, TRESHAUN
Entity Type:Individual
Prefix:
First Name:TRESHAUN
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 1:2831 HAMPSHIRE RD APT 3
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-1759
Mailing Address - Country:US
Mailing Address - Phone:216-699-5535
Mailing Address - Fax:
Practice Address - Street 1:2831 HAMPSHIRE RD APT 3
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1759
Practice Address - Country:US
Practice Address - Phone:216-699-5535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH264323172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver