Provider Demographics
NPI:1417401027
Name:LONG, ADAM (PT, DPT)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 RED PAINT RDG
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-1529
Mailing Address - Country:US
Mailing Address - Phone:931-220-9647
Mailing Address - Fax:
Practice Address - Street 1:1331 LAKE DR SE
Practice Address - Street 2:SUITE 105
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1674
Practice Address - Country:US
Practice Address - Phone:616-248-9842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MI5501017822225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer