Healthcare Provider Details

I. General information

NPI: 1417401027
Provider Name (Legal Business Name): ADAM LONG PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 LAKE DR SE SUITE 105
GRAND RAPIDS MI
49506-1674
US

IV. Provider business mailing address

104 RED PAINT RDG
CLARKSVILLE TN
37043-1529
US

V. Phone/Fax

Practice location:
  • Phone: 616-248-9842
  • Fax:
Mailing address:
  • Phone: 931-220-9647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501017822
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: