Provider Demographics
NPI:1598197238
Name:LONG, MARY BETH (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:LONG
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 ELLIOTT AVE APT 834
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-2141
Mailing Address - Country:US
Mailing Address - Phone:304-667-9388
Mailing Address - Fax:
Practice Address - Street 1:1755 WITTINGTON PL STE 175
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-1905
Practice Address - Country:US
Practice Address - Phone:214-442-4503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN312000225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist