Healthcare Provider Details

I. General information

NPI: 1659115509
Provider Name (Legal Business Name): HOLLY JEAN LONG LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 LONGLEY RD
GREENE ME
04236-3311
US

IV. Provider business mailing address

79 LONGLEY RD
GREENE ME
04236-3311
US

V. Phone/Fax

Practice location:
  • Phone: 207-891-9883
  • Fax:
Mailing address:
  • Phone: 207-891-9883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT6939
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: