Provider Demographics
NPI:1467520445
Name:LONG, STEPHENS EARL (PT)
Entity Type:Individual
Prefix:
First Name:STEPHENS
Middle Name:EARL
Last Name:LONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660046
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0046
Mailing Address - Country:US
Mailing Address - Phone:214-369-8555
Mailing Address - Fax:214-369-2683
Practice Address - Street 1:2200 LOS RIOS BLVD
Practice Address - Street 2:STE 132
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-3400
Practice Address - Country:US
Practice Address - Phone:972-509-5070
Practice Address - Fax:972-509-1557
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1054039225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX191639701Medicaid
TX8T7254OtherBCBS
TX8T7254OtherBCBS
TX8F22222Medicare PIN