MEDICARE: LESLIE LONG RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DT86033	TX

General Provider Information

NPI Number	:	1356292718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE LONG RD

Provider Business Mailing Address
First Line	:	602 BERNSTEIN ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-5510
Country	:	US
Telephone Number	:	512-549-9549
Fax Number	:

Provider Business Practice Location Address
First Line	:	602 BERNSTEIN ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-5510
Country	:	US
Telephone Number	:	512-549-9549
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2026
Last Update Date	:	02/03/2026

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Directions to “ LESLIE LONG RD” Practice Location

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