Provider Demographics
NPI:1710545777
Name:LONG, AMANDA (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:GUBBELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:647 SPIRIT AIRPARK WEST DR STE 101
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1032
Mailing Address - Country:US
Mailing Address - Phone:636-206-4225
Mailing Address - Fax:
Practice Address - Street 1:5200 EXECUTIVE CENTRE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-3394
Practice Address - Country:US
Practice Address - Phone:636-255-8750
Practice Address - Fax:636-244-1172
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9707225100000X
MO2021014458225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist