Provider Demographics
NPI:1851157093
Name:LONG, KATELYN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
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 1:147 W ESTEY ST
Mailing Address - Street 2:
Mailing Address - City:SHULLSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53586-9524
Mailing Address - Country:US
Mailing Address - Phone:815-275-4900
Mailing Address - Fax:
Practice Address - Street 1:2375 SINSINAWA RD
Practice Address - Street 2:
Practice Address - City:HAZEL GREEN
Practice Address - State:WI
Practice Address - Zip Code:53811-9707
Practice Address - Country:US
Practice Address - Phone:920-988-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5503-27224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant