Provider Demographics
NPI:1790481950
Name:LONG, REBECCA (LMT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:LONG
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 1:1036 GILSONITE AVE
Mailing Address - Street 2:
Mailing Address - City:MACK
Mailing Address - State:CO
Mailing Address - Zip Code:81525-1004
Mailing Address - Country:US
Mailing Address - Phone:970-773-1423
Mailing Address - Fax:
Practice Address - Street 1:518 28 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-6556
Practice Address - Country:US
Practice Address - Phone:970-773-1423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0013988225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1865Medicaid