Provider Demographics
NPI:1619546843
Name:LONG, ELIZABETH RENEE (LMT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RENEE
Last Name:LONG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18404 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:LAGO VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78645-8702
Mailing Address - Country:US
Mailing Address - Phone:512-639-7505
Mailing Address - Fax:
Practice Address - Street 1:18404 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:LAGO VISTA
Practice Address - State:TX
Practice Address - Zip Code:78645-8702
Practice Address - Country:US
Practice Address - Phone:512-639-7505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT134826225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist