Provider Demographics
NPI:1760039176
Name:LONG, DINA MARIE (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-4821
Mailing Address - Country:US
Mailing Address - Phone:908-216-6988
Mailing Address - Fax:
Practice Address - Street 1:315 E LINDSLEY RD
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1152
Practice Address - Country:US
Practice Address - Phone:973-754-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00982500235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty