Healthcare Provider Details

I. General information

NPI: 1841795465
Provider Name (Legal Business Name): KIMBERLY M LONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38250 A AVE
ZEPHYRHILLS, FL FL
33542
US

IV. Provider business mailing address

1427 HOLLY RD
LAKELAND FL
33801
US

V. Phone/Fax

Practice location:
  • Phone: 813-782-5508
  • Fax:
Mailing address:
  • Phone: 863-430-3177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA27309
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: