Provider Demographics
NPI:1912365743
Name:LONG, ELISE
Entity Type:Individual
Prefix:
First Name:ELISE
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 1:9851 HARRISON RD
Mailing Address - Street 2:APT. 230
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-2176
Mailing Address - Country:US
Mailing Address - Phone:515-745-3171
Mailing Address - Fax:
Practice Address - Street 1:7250 FRANCE AVE S
Practice Address - Street 2:SUITE 305
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-4305
Practice Address - Country:US
Practice Address - Phone:952-285-2840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105039225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist