Provider Demographics
NPI:1730482878
Name:LONG, SARA (PTA)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7411 112TH ST
Mailing Address - Street 2:
Mailing Address - City:BLUE GRASS
Mailing Address - State:IA
Mailing Address - Zip Code:52726-9121
Mailing Address - Country:US
Mailing Address - Phone:563-343-4735
Mailing Address - Fax:
Practice Address - Street 1:1209 21ST AVE
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-7900
Practice Address - Country:US
Practice Address - Phone:309-786-9334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004204225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant