Provider Demographics
NPI:1679840854
Name:LONG, CHINITA MAY PALLE (PT)
Entity Type:Individual
Prefix:MS
First Name:CHINITA MAY
Middle Name:PALLE
Last Name:LONG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CHINITA MAY
Other - Middle Name:DATAN
Other - Last Name:PALLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 829
Mailing Address - Street 2:
Mailing Address - City:INDIAN RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49749-0829
Mailing Address - Country:US
Mailing Address - Phone:941-585-6386
Mailing Address - Fax:
Practice Address - Street 1:351 S STRAITS HWY
Practice Address - Street 2:
Practice Address - City:INDIAN RIVER
Practice Address - State:MI
Practice Address - Zip Code:49749-9713
Practice Address - Country:US
Practice Address - Phone:941-585-6386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT26834225100000X
MI5501012476225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14399334OtherCAQH PROVIDER ID