Provider Demographics
NPI:1356616031
Name:LONG, LINDSEY (MED,CCC-SLP)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 CALIBRE CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4551
Mailing Address - Country:US
Mailing Address - Phone:706-975-8248
Mailing Address - Fax:
Practice Address - Street 1:205 LAKEMONT DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3203
Practice Address - Country:US
Practice Address - Phone:404-547-0825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007040235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist