Healthcare Provider Details

I. General information

NPI: 1174465223
Provider Name (Legal Business Name): STEPHANIE CATHERINE LONG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5127 W INDIAN SCHOOL RD # 161
PHOENIX AZ
85031-2611
US

IV. Provider business mailing address

955 W SOUTHERN AVE STE 101
MESA AZ
85210-4903
US

V. Phone/Fax

Practice location:
  • Phone: 623-245-7014
  • Fax: 623-247-0597
Mailing address:
  • Phone: 480-961-1702
  • Fax: 480-893-8172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT-002969
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: