Healthcare Provider Details

I. General information

NPI: 1376704882
Provider Name (Legal Business Name): VIRGINIA BREWER LONG MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 10/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PARKER LN
PINEHURST NC
28374-7903
US

IV. Provider business mailing address

153 RUDY LN
ROCKINGHAM NC
28379-7694
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-3133
  • Fax:
Mailing address:
  • Phone: 910-582-7046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3106
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: