Provider Demographics
NPI:1528401148
Name:LONGLEY, KYLIE ANN (COTA/L)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:ANN
Last Name:LONGLEY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3231
Mailing Address - Country:US
Mailing Address - Phone:360-425-9810
Mailing Address - Fax:360-425-1053
Practice Address - Street 1:1600 3RD AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3231
Practice Address - Country:US
Practice Address - Phone:360-425-9810
Practice Address - Fax:360-425-1053
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC 60345231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7018088Medicaid