Provider Demographics
NPI:1669816070
Name:LONG, MARY CATHERINE (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:LONG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 WOODVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35124-1021
Mailing Address - Country:US
Mailing Address - Phone:205-541-3679
Mailing Address - Fax:205-444-9190
Practice Address - Street 1:1709 WOODVIEW CIR
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:AL
Practice Address - Zip Code:35124-1021
Practice Address - Country:US
Practice Address - Phone:205-541-3679
Practice Address - Fax:205-444-9190
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11003RE246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other