Provider Demographics
NPI:1821227695
Name:LONG, VICTORIA O
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:O
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3948 LEGACY DR.
Mailing Address - Street 2:106 PMB# 155
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023
Mailing Address - Country:US
Mailing Address - Phone:214-558-7789
Mailing Address - Fax:
Practice Address - Street 1:4152 W SPRING CREEK PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-5314
Practice Address - Country:US
Practice Address - Phone:972-612-5363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT108736225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist