MEDICARE: LAURIE ELIZABETH LONGO

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1528620689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURIE ELIZABETH LONGO

Provider Business Mailing Address
First Line	:	1070 RANGE RD
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-4606
Country	:	US
Telephone Number	:	810-294-5097
Fax Number	:

Provider Business Practice Location Address
First Line	:	2828 17TH AVE
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-1804
Country	:	US
Telephone Number	:	810-841-6037
Fax Number	:

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

Provider Enumeration Date	:	06/28/2019
Last Update Date	:	06/28/2019

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Directions to “ LAURIE ELIZABETH LONGO ” Practice Location

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