Provider Demographics
NPI:1568839140
Name:LONG, JEREMY (DPT)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:LONG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4039 ROUTE 219
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-9625
Mailing Address - Country:US
Mailing Address - Phone:716-945-2484
Mailing Address - Fax:716-945-2487
Practice Address - Street 1:4039 ROUTE 219
Practice Address - Street 2:
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779-9625
Practice Address - Country:US
Practice Address - Phone:716-945-2484
Practice Address - Fax:716-945-2487
Is Sole Proprietor?:No
Enumeration Date:2015-08-30
Last Update Date:2015-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist