Provider Demographics
NPI:1013428333
Name:LONG, TISH KENNEDY (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:TISH
Middle Name:KENNEDY
Last Name:LONG
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:TISH
Other - Middle Name:KENNEDY
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:984B LASKIN RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-3905
Mailing Address - Country:US
Mailing Address - Phone:757-395-6970
Mailing Address - Fax:757-425-7180
Practice Address - Street 1:984B LASKIN RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-3905
Practice Address - Country:US
Practice Address - Phone:757-395-6900
Practice Address - Fax:757-425-7180
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist