Provider Demographics
NPI:1184728263
Name:LONG, JUSTIN WAYNE (MPT)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:WAYNE
Last Name:LONG
Suffix:
Gender:M
Credentials:MPT
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Mailing Address - Street 1:1013 SABLE CROSSING
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024
Mailing Address - Country:US
Mailing Address - Phone:417-234-9856
Mailing Address - Fax:770-271-1822
Practice Address - Street 1:2085 HAMILTON CREEK PKWY
Practice Address - Street 2:SUITE 160
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019
Practice Address - Country:US
Practice Address - Phone:770-271-1488
Practice Address - Fax:770-271-1822
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAPT008689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist