Provider Demographics
NPI:1659385813
Name:LONG, ALICA (MA CCC-A)
Entity Type:Individual
Prefix:
First Name:ALICA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MA CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GREEN AVE.
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-4045
Mailing Address - Country:US
Mailing Address - Phone:307-689-3611
Mailing Address - Fax:
Practice Address - Street 1:300 GREEN AVE.
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4045
Practice Address - Country:US
Practice Address - Phone:307-689-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYA-973237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE507621740Medicaid
NE235Medicaid
NEP00297942OtherPALMENTO GBA RR MEDICARE
NEW308228OtherSOUTH DAKOTA MEDICARE
NE235Medicaid
NE507621740Medicaid