Healthcare Provider Details

I. General information

NPI: 1356268510
Provider Name (Legal Business Name): GARY WAYNE LONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12686 WESTFALL RD
FRANKFORT OH
45628-9035
US

IV. Provider business mailing address

12686 WESTFALL RD
FRANKFORT OH
45628-9035
US

V. Phone/Fax

Practice location:
  • Phone: 740-466-7042
  • Fax:
Mailing address:
  • Phone: 740-466-7042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: