Provider Demographics
NPI:1811471592
Name:LONG, LESSIE ELLEN (CPS)
Entity type:Individual
Prefix:
First Name:LESSIE
Middle Name:ELLEN
Last Name:LONG
Suffix:
Gender:F
Credentials:CPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 HIGHWAY V V
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-3866
Mailing Address - Country:US
Mailing Address - Phone:573-359-2600
Mailing Address - Fax:
Practice Address - Street 1:925 HIGHWAY V V
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3866
Practice Address - Country:US
Practice Address - Phone:573-359-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist