Provider Demographics
NPI:1710523865
Name:LONGS, ERICA SIOBHAN (LMT)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:SIOBHAN
Last Name:LONGS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24901 NORTHWESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2203
Mailing Address - Country:US
Mailing Address - Phone:844-369-9955
Mailing Address - Fax:947-282-8576
Practice Address - Street 1:15848 CHEYENNE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-3614
Practice Address - Country:US
Practice Address - Phone:313-506-3482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501011456225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist