Provider Demographics
NPI:1780613091
Name:LONG, MARY TEW (MAT, ATC, LAT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:TEW
Last Name:LONG
Suffix:
Gender:F
Credentials:MAT, ATC, LAT
Other - Prefix:
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Mailing Address - Street 1:13717 RANDA PKWY
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35475-3473
Mailing Address - Country:US
Mailing Address - Phone:205-330-0998
Mailing Address - Fax:
Practice Address - Street 1:1325 MCFARLAND BLVD
Practice Address - Street 2:THE SPORTS AND MEDICINE COMPLEX
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3270
Practice Address - Country:US
Practice Address - Phone:205-333-4778
Practice Address - Fax:205-333-4776
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL0612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer