Provider Demographics
NPI:1649906033
Name:LONG, KELLY ANN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:LONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 S 66TH ST
Mailing Address - Street 2:
Mailing Address - City:CAVE SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72718-8447
Mailing Address - Country:US
Mailing Address - Phone:479-601-3537
Mailing Address - Fax:
Practice Address - Street 1:5710 S 66TH ST
Practice Address - Street 2:
Practice Address - City:CAVE SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72718-8447
Practice Address - Country:US
Practice Address - Phone:479-601-3537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR506235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist