Provider Demographics
NPI:1639183171
Name:LONG, MEGAN DENISE (OT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:DENISE
Last Name:LONG
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31037 HOLDEN DR
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52804
Mailing Address - Country:US
Mailing Address - Phone:563-370-3550
Mailing Address - Fax:
Practice Address - Street 1:31037 HOLDEN DR
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804
Practice Address - Country:US
Practice Address - Phone:563-359-4054
Practice Address - Fax:563-359-4084
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01348225X00000X
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA113357Medicare ID - Type Unspecified