Provider Demographics
NPI:1881262251
Name:LONG, MICHELE E
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:E
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 1:1803 STATE ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:NY
Mailing Address - Zip Code:13156-3126
Mailing Address - Country:US
Mailing Address - Phone:315-391-0110
Mailing Address - Fax:
Practice Address - Street 1:8395 OSWEGO RD
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-6801
Practice Address - Country:US
Practice Address - Phone:315-450-4898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1384290201OtherSTUDENTS WITH DISABILITIES BIRTH-2 TEACHING CERTIFICATE
NY1384444201OtherSTUDENTS WITH DISABILITIES 1-6 TEACHING CERTIFICATE