Provider Demographics
NPI:1629205943
Name:LONG, ALYSAN N (DPT)
Entity Type:Individual
Prefix:
First Name:ALYSAN
Middle Name:N
Last Name:LONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 E MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3719
Mailing Address - Country:US
Mailing Address - Phone:406-586-4678
Mailing Address - Fax:406-586-4670
Practice Address - Street 1:612 E MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3719
Practice Address - Country:US
Practice Address - Phone:406-586-4678
Practice Address - Fax:406-586-4670
Is Sole Proprietor?:No
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT2235225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist