Provider Demographics
NPI:1871648428
Name:LONG, REBECCA DANIELLE (LMP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:DANIELLE
Last Name:LONG
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 91ST DR SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98205-1882
Mailing Address - Country:US
Mailing Address - Phone:425-220-8602
Mailing Address - Fax:
Practice Address - Street 1:800-164TH ST SE
Practice Address - Street 2:SUITE N
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012
Practice Address - Country:US
Practice Address - Phone:425-742-6034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021888225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist