Provider Demographics
NPI:1508908880
Name:LONG, ROBERT WAYNE (CDP)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WAYNE
Last Name:LONG
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10215 214TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-3909
Mailing Address - Country:US
Mailing Address - Phone:253-862-7374
Mailing Address - Fax:253-862-0448
Practice Address - Street 1:10215 214TH AVE E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-3909
Practice Address - Country:US
Practice Address - Phone:253-862-7374
Practice Address - Fax:253-862-0448
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00002606174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist