Provider Demographics
NPI:1609285097
Name:LONG, MATTHEW BRENTON (OTR/L)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRENTON
Last Name:LONG
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W CULVERT ST
Mailing Address - Street 2:
Mailing Address - City:ZELIENOPLE
Mailing Address - State:PA
Mailing Address - Zip Code:16063-1580
Mailing Address - Country:US
Mailing Address - Phone:724-452-3492
Mailing Address - Fax:
Practice Address - Street 1:400 W CULVERT ST
Practice Address - Street 2:
Practice Address - City:ZELIENOPLE
Practice Address - State:PA
Practice Address - Zip Code:16063-1580
Practice Address - Country:US
Practice Address - Phone:724-452-3492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC012054225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist