Provider Demographics
NPI:1396438974
Name:LONG, MALLORY BREANNE (DPT)
Entity type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:BREANNE
Last Name:LONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1107 E MATTHEWS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4331
Mailing Address - Country:US
Mailing Address - Phone:870-933-6393
Mailing Address - Fax:870-933-6763
Practice Address - Street 1:1107 E MATTHEWS AVE STE 100
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4331
Practice Address - Country:US
Practice Address - Phone:870-933-6393
Practice Address - Fax:870-933-6763
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AR5281208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation