Provider Demographics
NPI:1972109361
Name:LONG, SONDRA STEPHANIE (LOTR, MOT)
Entity Type:Individual
Prefix:
First Name:SONDRA
Middle Name:STEPHANIE
Last Name:LONG
Suffix:
Gender:F
Credentials:LOTR, MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5257 BLUEBIRD LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2490
Mailing Address - Country:US
Mailing Address - Phone:318-780-5619
Mailing Address - Fax:
Practice Address - Street 1:5201 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-3527
Practice Address - Country:US
Practice Address - Phone:318-640-3014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200222225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist