Provider Demographics
NPI:1669937447
Name:LONG, LAUREN MICHELLE (COTA/L)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:MICHELLE
Last Name:LONG
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 NESMITH RD
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35031-6717
Mailing Address - Country:US
Mailing Address - Phone:256-585-5925
Mailing Address - Fax:
Practice Address - Street 1:530 SPARKMAN ST SW
Practice Address - Street 2:
Practice Address - City:HARTSELLE
Practice Address - State:AL
Practice Address - Zip Code:35640-3120
Practice Address - Country:US
Practice Address - Phone:256-585-5925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3873224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL336814Medicaid