Provider Demographics
NPI:1578696118
Name:LONG, ANGIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 GREENBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-5423
Mailing Address - Country:US
Mailing Address - Phone:432-262-1004
Mailing Address - Fax:
Practice Address - Street 1:620 N ALLEGHANEY AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4408
Practice Address - Country:US
Practice Address - Phone:432-332-8244
Practice Address - Fax:432-580-7428
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105493225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105493OtherSTATE LICENSE NUMBER
TX8T4670OtherBCBS PROVIDER NUMBER