Provider Demographics
NPI:1568617314
Name:LONG, DONNA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 OKEECHOBEE RD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-5414
Mailing Address - Country:US
Mailing Address - Phone:772-462-6636
Mailing Address - Fax:772-462-6635
Practice Address - Street 1:4202 OKEECHOBEE RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-5414
Practice Address - Country:US
Practice Address - Phone:772-462-6636
Practice Address - Fax:772-462-6635
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5860235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist