Provider Demographics
NPI:1417011842
Name:LONG, CHRISTINE MARIE (AUD)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:ACHUFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:923 ELIZA ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3234
Practice Address - Country:US
Practice Address - Phone:920-965-4800
Practice Address - Fax:920-965-4801
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI443156231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41147600Medicaid