Provider Demographics
NPI:1619922374
Name:LONG, CARMEN LORRAINE (OTR L)
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:LORRAINE
Last Name:LONG
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:MISS
Other - First Name:CARMEN
Other - Middle Name:LORRAINE
Other - Last Name:NAHLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR L
Mailing Address - Street 1:9000 N RODNEY PARHAM RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-1646
Mailing Address - Country:US
Mailing Address - Phone:501-503-5160
Mailing Address - Fax:501-503-5160
Practice Address - Street 1:9000 N RODNEY PARHAM RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-1646
Practice Address - Country:US
Practice Address - Phone:501-503-5160
Practice Address - Fax:501-503-5160
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR142225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116099721Medicaid