Provider Demographics
NPI:1912324617
Name:LONG, DENISE (RD)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:LONG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 GENESEE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14611-4047
Mailing Address - Country:US
Mailing Address - Phone:585-698-3661
Mailing Address - Fax:
Practice Address - Street 1:62 GENESEE PARK BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14611-4047
Practice Address - Country:US
Practice Address - Phone:585-698-3661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006026133V00000X
NY896072133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered