Provider Demographics
NPI:1598497497
Name:LONG, KATHERINE THERESE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:THERESE
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:THERESE
Other - Last Name:MADSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3737 LANDER RD
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5712
Mailing Address - Country:US
Mailing Address - Phone:931-217-9912
Mailing Address - Fax:
Practice Address - Street 1:3737 LANDER RD
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-5712
Practice Address - Country:US
Practice Address - Phone:931-217-9912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSC285102171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2871101Medicaid