Provider Demographics
NPI:1821581661
Name:LONG, SANDRA M (MA CCC SLP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:M
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 1:11691 VICTOR DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-5213
Mailing Address - Country:US
Mailing Address - Phone:303-775-9677
Mailing Address - Fax:
Practice Address - Street 1:11691 VICTOR DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80504-5213
Practice Address - Country:US
Practice Address - Phone:303-775-9677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20141416743235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20141416743OtherCOLORADO SECRETARY OF STATE/DORA