Provider Demographics
NPI:1205424546
Name:LONG, NATHAN ANDREW (AUD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:ANDREW
Last Name:LONG
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:DR
Other - First Name:NATHAN
Other - Middle Name:ANDREW
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AUD
Mailing Address - Street 1:215 RIVERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5256
Mailing Address - Country:US
Mailing Address - Phone:770-345-6600
Mailing Address - Fax:
Practice Address - Street 1:215 RIVERSTONE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5256
Practice Address - Country:US
Practice Address - Phone:770-345-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004250231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist