Provider Demographics
NPI:1912326018
Name:DELONG, KIM (LMT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:DELONG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 W HILL PL
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-3042
Mailing Address - Country:US
Mailing Address - Phone:406-799-8980
Mailing Address - Fax:
Practice Address - Street 1:1909 W HILL PL
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-3042
Practice Address - Country:US
Practice Address - Phone:406-799-8980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT660174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist