Provider Demographics
NPI:1609355197
Name:LONG, CLARICE (DPT)
Entity Type:Individual
Prefix:
First Name:CLARICE
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 1:9107 MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424
Mailing Address - Country:US
Mailing Address - Phone:806-687-4311
Mailing Address - Fax:806-687-4313
Practice Address - Street 1:410 AVENUE G
Practice Address - Street 2:
Practice Address - City:LEVELLAND
Practice Address - State:TX
Practice Address - Zip Code:79336-3719
Practice Address - Country:US
Practice Address - Phone:806-897-0540
Practice Address - Fax:806-897-0542
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1307671225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist