Healthcare Provider Details

I. General information

NPI: 1194418483
Provider Name (Legal Business Name): COURTNEY D LONG OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 COLEMANS CROSSING BLVD
MARYSVILLE OH
43040-7115
US

IV. Provider business mailing address

500 LONDON AVE
MARYSVILLE OH
43040-3570
US

V. Phone/Fax

Practice location:
  • Phone: 937-578-7841
  • Fax: 937-578-7891
Mailing address:
  • Phone: 937-644-6115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32003385A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31008185A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT012695
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: