Provider Demographics
NPI:1205248325
Name:LONG, REBECCA (CLINICAL SPECIALIST)
Entity type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:CLINICAL SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 221
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22553-0221
Mailing Address - Country:US
Mailing Address - Phone:540-656-6254
Mailing Address - Fax:
Practice Address - Street 1:7420 BROCK RD
Practice Address - Street 2:
Practice Address - City:SPOTSYLVANIA
Practice Address - State:VA
Practice Address - Zip Code:22553-2002
Practice Address - Country:US
Practice Address - Phone:540-656-6254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2016-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA857084174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist