Provider Demographics
NPI:1629716501
Name:LONG, DANIELLE (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 LISA ST APT K3
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-9351
Mailing Address - Country:US
Mailing Address - Phone:912-224-5538
Mailing Address - Fax:
Practice Address - Street 1:51 RIVERWALK BLVD UNIT 3B
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-3201
Practice Address - Country:US
Practice Address - Phone:843-781-4432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-21
Last Update Date:2022-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12339225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty