Provider Demographics
NPI:1649403924
Name:LONG, HOLLY (PT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 DICK LONAS RD UNIT 101
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1383
Mailing Address - Country:US
Mailing Address - Phone:865-500-2143
Mailing Address - Fax:865-381-1509
Practice Address - Street 1:380 W BROADWAY BLVD STE 130
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-2602
Practice Address - Country:US
Practice Address - Phone:865-475-4742
Practice Address - Fax:833-908-2080
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1441225100000X
TN12118225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist