Provider Demographics
NPI:1790716090
Name:LONG, CARRIE (AT)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 S ADAMS ST
Mailing Address - Street 2:APT 02
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2139
Mailing Address - Country:US
Mailing Address - Phone:812-275-2660
Mailing Address - Fax:812-276-1304
Practice Address - Street 1:1600 23RD ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-4704
Practice Address - Country:US
Practice Address - Phone:812-275-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001215A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer