Provider Demographics
NPI:1598379943
Name:LONG, STEFANIE (DPT)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 CREEK BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-6834
Mailing Address - Country:US
Mailing Address - Phone:832-563-5259
Mailing Address - Fax:
Practice Address - Street 1:704 CREEK BLUFF DR
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-6834
Practice Address - Country:US
Practice Address - Phone:832-563-5259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1186869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist