Provider Demographics
NPI:1821531633
Name:LONG, TERESE (MS CCC-SLP TSSLD)
Entity Type:Individual
Prefix:
First Name:TERESE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MS CCC-SLP TSSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 QUENTIN RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4241
Mailing Address - Country:US
Mailing Address - Phone:718-998-4298
Mailing Address - Fax:
Practice Address - Street 1:3301 QUENTIN RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-4241
Practice Address - Country:US
Practice Address - Phone:718-998-4298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019576235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist