Provider Demographics
NPI:1790016475
Name:LONG, PAMELA A (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:A
Last Name:LONG
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20706 23RD RD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-1325
Mailing Address - Country:US
Mailing Address - Phone:917-502-0555
Mailing Address - Fax:
Practice Address - Street 1:20706 23RD RD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360-1325
Practice Address - Country:US
Practice Address - Phone:917-502-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011014-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist