Healthcare Provider Details

I. General information

NPI: 1063552404
Provider Name (Legal Business Name): KAI JEANINE LONG M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 SOUTHPARK BLVD SUITE 100
ST AUGUSTINE FL
32086-4120
US

IV. Provider business mailing address

605 TWENTY SECOND STREET
ST. AUGUSTINE FL
32084
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-1478
  • Fax:
Mailing address:
  • Phone: 904-824-6924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA8605
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: