Provider Demographics
NPI:1417499062
Name:LONG, TYLER AUSTIN (ATC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:AUSTIN
Last Name:LONG
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 WHEAT ST
Mailing Address - Street 2:OFFICE 214
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29208-0001
Mailing Address - Country:US
Mailing Address - Phone:636-699-0078
Mailing Address - Fax:
Practice Address - Street 1:1300 WHEAT ST
Practice Address - Street 2:OFFICE 214
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29208-0001
Practice Address - Country:US
Practice Address - Phone:636-699-0078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-14
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20000255342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer