Provider Demographics
NPI:1972034684
Name:LONG, TIERRA (OTR/L)
Entity Type:Individual
Prefix:
First Name:TIERRA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:TIERRA
Other - Middle Name:JON'TE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:4080 FIREOAK DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-3881
Mailing Address - Country:US
Mailing Address - Phone:301-437-1241
Mailing Address - Fax:
Practice Address - Street 1:739 WEST PEACHTREE STREET NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308
Practice Address - Country:US
Practice Address - Phone:404-602-4345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006410225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist